AHPSR PRIMASYS Pakistan Comprehensive v2

PRIMARY HEALTH CARE SYSTEMS
(PRIMASYS)
Comprehensive case study from Pakistan
PRIMARY HEALTH CARE SYSTEMS
(PRIMASYS)
Comprehensive case study from Pakistan
Shehla Zaidi, Nasir Idrees, Atif Riaz
Aga Khan University, Department of Community Health Services

WHO/HIS/HSR/17.37
© World Health Organization 2017
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PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Contents
Abbreviations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1
Background to PRIMASYS case studies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .2
1. Background to Pakistan case study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
1.1 Primary health care in Pakistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .3
1.2 Objectives of the case study . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3
2. Methodology . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 4
3. Pakistan: country profile . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
4. Introduction to primary health care in Pakistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .7
5. Governance architecture for primary health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .8
5.1 Health planning: power and authority in the pre- and post‑devolution context . . . . . . . . . . . . 8
5.2 Integration of services and programmes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .9
5.3 Integration of health and other service sectors . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9
6. Health financing and fund flows . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
6.1 Financing sources and spending . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
6.2 Financing mechanisms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
6.3 Fiscal flows to support primary health care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13
6.4 Integration of financing decisions with primary care decisions . . . . . . . . . . . . . . . . . . . . . 13
7. Service organization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
7.1 Governmental and semi-governmental PHC provision . . . . . . . . . . . . . . . . . . . . . . . . . 16
7.2 Private sector . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
8. Human resources for health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19
9. Planning and implementation for PHC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
9.1 Stewardship . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21
9.2 Challenges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
9.3 Recent innovations for PHC . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22
10. Health information systems . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 24
11. Regulation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
11.1 Drugs and essential technologies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
11.2 Human resources production and training . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26
11.3 Health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
11.4 Other areas . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 27
COMPREHENSIVE CASE STUDY FROM PAKISTAN

12. Outcomes: coverage of and access to essential services . . . . . . . . . . . . . . . . . . . . . . . . . 28
12.1 Coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
12.2 Uneven service coverage . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
12.3 Income differentials in service access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
12.4 Spending on health by income groups . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
12.5 Utilization of government PHC facilities by income groups . . . . . . . . . . . . . . . . . . . . . . . 31
12.6 Barriers to access . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
12.7 Efficiency . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31
12.8 Quality of private health sector in Pakistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
12.9 Continuum of care . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 32
12.10 Health co-production . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 33
13. Pathways of success and failure in primary health care . . . . . . . . . . . . . . . . . . . . . . . . . . 34
13.1 Decentralization of decisions for health care management and services . . . . . . . . . . . . . . . 34
13.2 Type and extent of purchasing arrangements . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 36
13.3 Government capacity to manage partnership agreements . . . . . . . . . . . . . . . . . . . . . . 38
13.4 Integration of vertical programme structures . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40
Annex 1. Key demographic, macroeconomic and health indicators of Pakistan . . . . . . . . . . . . . 42
Annex 2. Demographic, macroeconomic and health profile of Pakistan . . . . . . . . . . . . . . . . . 43
Annex 3. Basic information on Pakistan health system . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44
Annex 4. Focus group discussion participants . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45
References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 48

iv
Figures
Figure 1. Country data on noncommunicable diseases, Eastern Mediterranean region 2014 . . . . . .6
Figure 2. Health expenditures by financing agents . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 11
Figure 3. Government health expenditure as % of provincial government expenditure . . . . . . . . 13
Figure 4. Recurrent expenditure: Basic health units and rural health centres in Pakistan . . . . . . . . 14
Figure 5. Comparison of private health sector utilization in Eastern Mediterranean Region countries . 18
Figure 6. Human resources for health in Pakistan: ratio of workforce to population . . . . . . . . . . . 19
Figure 7. Urban–rural distribution of human resources for health, Pakistan . . . . . . . . . . . . . . . . 20
Figure 8. Trends in coverage for key health services . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 28
Figure 9. Proportion of health expenditure from total income (%) . . . . . . . . . . . . . . . . . . . . . 29
Figure 10. Provincial share of budget to health . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35
Figure 11. Consolidated health budget 2008–2013: federal, provincial and district shares (%) . . . . 36
Tables
Table 1. Key health indicators of Pakistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .5
Table 2. Government health expenditure by category . . . . . . . . . . . . . . . . . . . . . . . . . . . . 12
Table 3. Health spending and utilization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15
Table 4. Health facilities by type . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 16
Table 5. Sources of care in Pakistan (%) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17
Table 6. Human resources for health in Pakistan: numbers in selected cadres . . . . . . . . . . . . . . 19
Table 7. Policy and programmatic initiatives for PHC in Pakistan . . . . . . . . . . . . . . . . . . . . . . 22
Table 8. Health information system: national implementation . . . . . . . . . . . . . . . . . . . . . . . 24
Table 9. Mother and child care: micronutrient supplementation, feeding practices, and
undernutrition management . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29
Table 10. Health and nutrition intervention coverage among wealth quintiles in the four
provinces of Pakistan . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 30
Table 11. Basic health unit consumers by income/wealth quintile . . . . . . . . . . . . . . . . . . . . . 31
Table 12. Quality indicators for diabetes mellitus management in outpatient settings . . . . . . . . . 32
Table 13. Reasons for using basic health units given by those who received services (%) . . . . . . . 39

v
vi
Abbreviations
DHIS District Health Information System PC1 Planning Commission form 1
DOTS directly observed treatment, short course PHC primary health care
GDP gross domestic product PPHI People’s Primary Healthcare Initiative
MIS Management Information System UNICEF United Nations Children’s Fund
NCD noncommunicable disease WHO World Health Organization
NGO nongovernmental organization

1
Background to PRIMASYS case studies
Health systems around the globe still fall short of The Alliance has developed full and abridged versions
providing accessible, good-quality, comprehensive of the 20 PRIMASYS case studies. The abridged
and integrated care. As the global health community version provides an overview of the primary health
is setting ambitious goals of universal health care system, tailored to a primary audience of policy-
coverage and health equity in line with the 2030 makers and global health stakeholders interested in
Agenda for Sustainable Development, there is understanding the key entry points to strengthen
increasing interest in access to and utilization of primary health care systems. The comprehensive case
primary health care in low- and middle-income study provides an in-depth assessment of the system
countries. A wide array of stakeholders, including for an audience of researchers and stakeholders who
development agencies, global health funders, policy wish to gain deeper insight into the determinants
planners and health system decision-makers, require and performance of primary health care systems
a better understanding of primary health care in selected low- and middle-income countries.
systems in order to plan and support complex health Furthermore, the case studies will serve as the basis
system interventions. There is thus a need to fill the for a multicountry analysis of primary health care
knowledge gaps concerning strategic information systems, focusing on the implementation of policies
on front-line primary health care systems at national and programmes, and the barriers to and facilitators
and subnational levels in low- and middle-income of primary health care system reform. Evidence from
settings. the case studies and the multi-country analysis will
in turn provide strategic evidence to enhance the
The Alliance for Health Policy and Systems
performance and responsiveness of primary health
Research, in collaboration with the Bill & Melinda
care systems in low- and middle-income countries.
Gates Foundation, is developing a set of 20 case
studies of primary health care systems in selected
low- and middle-income countries as part of an
initiative entitled Primary Care Systems Profiles
and Performance (PRIMASYS). PRIMASYS aims to
advance the science of primary health care in low-
and middle-income countries in order to support
efforts to strengthen primary health care systems
and improve the implementation, effectiveness
and efficiency of primary health care interventions
worldwide. The PRIMASYS case studies cover key
aspects of primary health care systems, including
policy development and implementation,
financing, integration of primary health care into
comprehensive health systems, scope, quality and
coverage of care, governance and organization, and
monitoring and evaluation of system performance.

2
1. Background to Pakistan case study
1.1 Primary health care in Pakistan 1.2 Objectives of the case study
The primary health care (PHC) system is the Objectives of this case study are twofold:
cornerstone to any health system for providing
• to develop a descriptive case study summarizing
accessible, good-quality, responsive, equitable and
primary care systems at country level;
integrated care. The importance of PHC has been
• to contribute to cross-cutting lessons across
recognized in the past few decades, and recently
countries to inform the performance of primary
there has been increasing interest in primary care to
care systems.
achieve the goal of universal health coverage across
both developed and developing economies. The report first maps the PHC architecture in
Research has mostly addressed PHC-related health Pakistan, and the underlying dynamics of policy
outcomes, including coverage, quality and equity and implementation that shape its delivery, in the
aspects. Less work has been done on analysing following areas:
complex mechanisms of planning, governing and • primary care structure: service organization,
regulating the PHC subsector within health. A governance, financing, and human resources;
deeper understanding is also needed to identify • processes affecting primary care: planning
and record pathways of success and failure for PHC and implementation, regulation of PHC, and
in a systematic way, particularly in low- and middle- Management Information System (MIS);
income countries. • outcomes: discussion of coverage, equitable
This study aims to capture the dimensions of the access, quality and responsiveness of care, and
PHC sector in Pakistan in terms of its structures quality and safety of services.
and processes, and the tangible as well as the less
The principles of relevance, trustworthiness and
tangible outcomes. It also picks up four pathways
coherence ere cross-cutting principles across the
of recent change within the PHC system, and looks
three strands.
at interconnections between the PHC structure,
processes and outcomes in shaping success, as well The report then goes on to draw lessons from reform
as the related constraints. initiatives in Pakistan and outlines the specific
pathways of success and failure in the area of PHC
The study aims to bridge the gap in front-line health
in the country.
care delivery systems at national and subnational
levels; to provide insight into how PHC systems
operate in a low- and middle-income country
settings; and to identify what can be learned from
the PHC experience.

3
2. Methodology
A case study design was used to describe and analyse barriers to recent reforms in order to learn lessons
various aspects of the PHC system in Pakistan, on the implications for governance and service
following the PRIMASYS framework, methodology delivery at the primary care level. The round tables
and template, as described in the background to had a diverse representation of stakeholders from
PRIMASYS case studies above. nongovernmental organizations (NGOs), expert
groups, government and international development
Methods included documentary review, key
partners. Questions on pathways were introduced to
informant interviews, and focus group discussions.
explore progress, success and barriers. Also, care was
Documentary evidence included published surveys,
taken to ensure that the selection of stakeholders
independent assessment of reform initiatives, peer-
was diverse, representing a spread of different tiers
reviewed articles, and policy strategy and planning
and different levels of the health system (ensuring
documents. The documentation was first gathered
maximum variability). Stakeholder discussions
and reviewed, and then important fixed and flexible
were focused on fact-finding to address specific
elements of inquiry were identified for further
information requirements, and also on eliciting
probing through the interviews. Key informant
different perspectives of relevant processes, and
interviews were conducted with 15 stakeholders,
interpretation and contextualization of available
including vertical programme managers, district
quantitative findings.
health officers, representatives of provincial health
departments and ministry officials. Preference was Triangulation of findings from all sources was done
given to stakeholders that had either been part of for synthesis and report writing. A narrative synthesis
the process of the particular pathways or had an and collation approach was used for descriptive
oversight of the historical background during the sections and thematic synthesis for identifying
period. The focus group discussions were carried pathways of success and failure.
out in association with national round-table policy
The study received approval from Ethics Review
discussions under way to develop the national
Committee of Aga khan University, Karachi. Informed
policy vision, and aimed to capture successes of and
consent was obtained from all participants of the study.

4
3. Pakistan: country profile
Pakistan is the sixth most populous country of declining from 5.4 in 1990 (2), but little change is
the world, with a total population estimated seen in rural areas. Undernutrition is a chronic, long-
at 184.35 million (1). The male–female ratio is standing issue in all provinces, as seen by high levels
102:100 (50.8% males and 49.2% females (2), and of stunting and with little evidence of decrease (and
the population density is 231 people per square in some cases, a deterioration) over the past decade
kilometre, with 61.4% of the population living in rural (6). Table 1 summarizes the key health indicators
areas and 38.6% in urban areas. The average growth for Pakistan. The overall health scenario in Pakistan
rate is 2%, while the literacy rate is 43.4% (2). The indicates the potential for increased investment in
gross domestic product (GDP) per capita is US$ 1317 health in order to achieve major gains, especially in
and the GDP growth is 4.7%, and Pakistan is ranked as the area of maternal and child health outcomes.
a lower middle-income country (3). Around 33% of
There is a rising trend of noncommunicable diseases
its population lives below the poverty line, with clear
(NCDs), which now account for 50% of total deaths
disparities in poverty status between and within the
(8). There has also been a significant burden of
provinces (4). In addition, 8.5% of the population do
injuries and mental health problems, aside from
not have access to safe drinking water, while 17% do
other chronic NCD conditions (Figure 1, next page).
not have access to proper sanitation facilities (5).
Pakistan’s key health indicators are not promising,
Table 1. Key health indicators of Pakistan
and did not attain the Millennium Development Goal
2015 targets. Neonatal mortality is 55 per 1000 live Source of
Key indicators Figures information
births, an indicator that has remained stagnant over Neonatal mortality rate 55/1000 PDHS 2012–13 (2)
the last 20 years. However, the infant mortality rate
Infant mortality rate 74/1000 PDHS 2012–13
has decreased by 19%, while under-5 mortality has
decreased by 24% over the same period. Currently Under-5 mortality rate 89/1000 PDHS 2012–13
the total fertility rate is 3.8 births per woman, Maternal mortality ratio 274/100 000 PDHS 2006–07 (7)
Total fertility rate 3.8 births per woman PDHS 2012–13
Underweight: children 31.5% NNS 2011 (6)
Stunting: children 43.7% NNS 2011
Wasting: children 15.1% NNS 2011
Anaemia: children 62.0% NNS 2011
Anaemia: pregnant 51.0% NNS 2011

mothers

5
Figure 1. Country data on noncommunicable diseases, Eastern Mediterranean region 2014
Somalia 19%
Sudan 34%
Djibouti 36%
Afghanistan 37%
Yemen 39%
Syrian Arab Republic 46%
Pakistan 50%
Iraq 62%
United Arab Emirates 65%
Oman 68%
Qatar 69%
Kuwait 73%
Morocco 75%
Iran 76%
Jordan 76%
Saudi Arabia 78%
Libya 78%
Bahrain 78%
Tunisia 82%
Lebanon 85%
Egypt 85%
Source: World Health Organization (8).

6
4. Introduction to primary health care in Pakistan
Pakistan, since its creation in 1947, has had mixed included the eradication of smallpox in 1974, and
success in establishing its health portfolio during the the national Expanded Programme of Immunization
ensuing decades. Significant crests and troughs have targeting vaccine-preventable childhood diseases,
been experienced, characterized by inequity, urban– launched in 1978. Diarrhoea control through oral
rural disparities, inadequate resource allocation, an rehydration solutions and training of traditional
imbalance in the number and skills mix of health birth attendants on safe and clean delivery were
workers, and deficient access to quality health care also introduced, aiming to reduce both infant and
for all segments of the population. maternal mortality. In late 1993 the Lady Health
Worker Programme was instigated to ensure home
During the 1960s and 1970s, much emphasis was
delivery of such health services as antenatal and
given to strengthening the infrastructure of the
postnatal care, childhood disease prevention and
health care system and establishment of rural health
family planning. Provision of directly observed
centres in order to bring health services closer to the
treatment, short course (DOTS) to the population
community. The 1970s and 1980s can be considered
suffering from tuberculosis was started in 2001, and
as the decades of PHC, when the international public
the Roll Back Malaria initiative was launched in 1998.
health movement was given considerable stimulus
Efforts to combat undernutrition through infant and
by the Alma-Ata Declaration on Primary Health
young child feeding, malnutrition treatment and
Care in September 1978. The initiatives in Pakistan
food fortification were launched in 2015.

7
5. Governance architecture for primary health care
5.1 Health planning: power to the district level. The aim was to enhance local
accountability and improve service delivery. In
and authority in the pre- and
health, devolution did not change the role of the
post‑devolution context federal government, but rather the division of
Pakistan is a federation with three levels of responsibilities between the provinces and the
government – federal, provincial and district. districts. The Local Government Ordinance was
The Capital Territory of Islamabad, the Federally repealed a few years later after facing a number of
Administered Tribal Areas and the Federally blurred administrative responsibilities, low technical
Administered Northern Areas come under the capacity, and lack of visible improvement, with some
jurisdiction of the federal government, whereas Azad reversals, in service delivery.
Jammu and Kashmir is an autonomous region with
In 2011, the 18th Amendment to the Constitution
its own government.
of Pakistan, unanimously passed by all political
The provision of health services – including parties, devolved 21 sectors (including health) to
planning, management and oversight, financing, the provinces and set up a Council of Common
implementation, medical education and training, Interest headed by the Prime Minister and provincial
monitoring and supervision, and regulation – chief ministers to settle major interprovincial issues.
has been the provincial governments’ primary Policy, legislation, programming, implementation,
responsibility under the 1973 Constitution of budgeting and monitoring were devolved to the
Pakistan, while the federal government’s primary provinces. The fiscal space of provinces was also
responsibility has been stewardship, including policy increased to allow for greater contribution to
development and strategy outlining, monitoring devolved subjects, while the federal fiscal space
and evaluation, health communication, advocacy was reduced. The exclusive federal roles remained
and information, formulation of technical values and international agreements, trade, and medical
guidelines, and the prevention of communicable surveillance of ports and borders, while roles in
diseases. However, the federal ministry’s role grew consultation with provinces included regulation of
beyond oversight with increasing involvement in professions, services and insurance, health planning
the funding and management of vertical preventive coordination with provinces, health information
programmes, as well as construction of large coordination with provinces, research, and
hospitals and medical colleges at the provincial level, coordination on interprovincial matters. The Federal
while the role of provincial governments became Ministry of Health was initially abolished, with federal
operational delivery of public health programmes functions assigned to other federal entities (for
and clinical services. example the Planning Commission and the Bureau of
Statistics); however, it was later reconstituted as the
This system continued until the local devolution
Ministry of National Health Service Coordination and
initiative in 2000, which was put in place under the
Regulation, bringing together the dispersed federal
military regime of General Musharraf as part of an
health functions into a single entity. Following the
apolitical series of reforms to achieve the agenda
2011 devolution, the federal government (until 2016)
of enlightened moderation. The Local Government
still remains responsible for partial budget support to
Ordinance of 2001 devolved the planning,
a series of mainly preventive national programmes.
administrative, supervision and financial powers
for 13 sectors, including health, from the provincial

8
5.2 Integration of services and and the media, resulting in little time for attention
programmes to routine immunization, which has failed to meet
national targets. Moreover, primary care services
Pakistan has a long history of implementing vertical at health facilities are affected due to staff duties
programmes, most of which originated as a result of on Polio Day. Similarly, the Lady Health Worker
similar global initiatives. In the context of Pakistan’s Programme, which is the largest community health
development system, some were termed “umbrella worker programme in the region, has been criticized
projects” (Expanded Programme on Immunization for diverging from its main role of awareness raising
and Lady Health Worker Programme), and some on birth spacing and mother and child health, with
were implemented as comprehensive projects – monthly visits of health workers mainly tied to Polio
separate provincial PC1 forms (Planning Commission Day administration.
form 1), with national PC1 forms for federal functions
(for example HIV/AIDS). Vertical programmes have 5.3 Integration of health and other
been criticized in Pakistan for duplication of services, service sectors
resulting in inefficiency of human resources, finances,
Health and population control had been organized
monitoring systems, time and logistics. Moreover,
apart under two distinct ministries and separate
uniformity of services is not ensured, as different
provincial departments. Following devolution there
vertical programmes are in different phases of
is now a single federal ministry dealing with health
implementation and focus on different geographical
and population, though both continue to have
areas and target populations. Erosion of district-
separate ministries in the provinces. The population
level accountability has also been witnessed – few
welfare sector has its own network of reproductive
decisions were left with district health offices as
health facilities providing long-acting and short-
programming, human resources management and
acting contraceptive devices, and also has separate
logistics supply for key areas were centralized into
cadres of village-based population workers for
the vertical programmes.
client motivation and distribution of contraceptives.
Polio eradication campaigns have also constrained Having separate structures has led to duplication of
the delivery of integrated routine immunization services and lack of an effective strategy.
services and have interrupted the continued
Nutrition has greater integration with health and
delivery of services at health facilities and in outreach
other sectors. Nutrition is institutionalized as a cross-
circumstances. These campaigns, started in 1994 as
sectoral matter in the National Planning Commission
special door-to-door campaigns to administer polio
and the provincial planning and development
drops, initially involved a week’s campaign every
departments, and an Intersectoral Nutrition Strategy
quarter and have now been stepped up to one
is in place for mainstreaming into different ministries.
or two campaigns every month. Each campaign
Provincial health ministries have recently started a
involves outreach lady health workers, vaccinators,
programme for nutrition-specific interventions as
staff of first-level care facilities and district health
part of the Intersectoral Nutrition Strategy. Health
offices, district administration staff and even the
sector delivery is focused at the primary care level,
law enforcement agencies in high-risk areas. Tight
involving infant and young child feeding practices,
programming involves national, provincial and
micronutrient supplementation, fortification, and
district levels and is vertically accountable beyond
treatment of malnourished children. These elements
the provincial and national health ministries to the
are integrated into the service package of health
civil administration and the executive leadership.
facilities and the Lady Health Worker Programme.
Special polio campaigns capture the time and Other ministries dealing with water, sanitation
resources of the health leadership, local government and hygiene, agriculture, food, and education are

9
programming nutrition-sensitive interventions as However, the cash transfer is unconditional and
part of the implementation of the Intersectoral presently is not linked to health conditionalities
Nutrition Strategy. such as immunization or antenatal care. It has
been used to promote primary school enrolment
Pakistan has one of the world’s largest cash transfer
and adult skill-building initiatives but has yet to be
programmes – the Benazir Income Support
leveraged towards PHC. A microinsurance scheme
Programme, which aims to alleviate poverty and
aimed at hospital care was started for beneficiaries
food insecurity. The programme has a detailed
of the Benazir Income Support Programme in a
poverty scorecard-based targeting system to identify
few districts, but was concluded without a formal
and provide cash transfers to low-income women.
evaluation.

10
6. Health financing and fund flows
6.1 Financing sources and spending Government spending as a proportion of total
health expenditure is 36.8% inclusive of federal,
Pakistan spends 2.8% of GDP on health, while the
provincial and district government, armed forces and
total government health expenditure as a proportion
parastatal agencies. Household spending as a share
of GDP is 0.8% (9). The major funding source for
of total expenditure on health is 55% (3); local NGO
government spending is from centrally collected
spending is 6%, social security is 3%, and the donor
taxes. Earmarking of taxes, such as revenues from
contribution is 2% (Figure 2).
tobacco excise tax, locally generated taxes, and
corporate sector tax for social contribution, has The largest share of out-of-pocket spending has been
as yet not been tapped for health spending. For on medicines (67%), followed by consultation (23%)
household spending, out-of-pocket payments are and transport (10%). Within government spending
the major source of household spending, with the largest proportion is consumed by general
minimal coverage of private voluntary insurance. The hospital services, followed by administration and
Zakat religious charity tax as well as philanthropic planning, then medical colleges and lastly preventive
contributions from private corporations and citizens health programmes (Table 2).
are the main source of funds for the local NGO sector.
Figure 2. Health expenditures by financing agents
District Govt. 7.6% Military Health 3%

Donors 2%
Federal &
Private Prov. Govt.
55%
Social
23.6% Security 1.06%
Autonomous 1.7%
Local NGOs 6.04%
Source: National Health Accounts 2011–12 (9).

11
Table 2. Government health expenditure by arrangements have been put in place whereby
category the government has outsourced the management
2012/2013 basic of basic health units to the NGO sector while
Category expenditure continuing to provide the budget for health services.
Provincial executive 7 The government still has to move to expanding its
Planning (general public service) 17 703 coverage through purchasing services provided by
Construction and transport 7 544 private sector institutions.
Therapeutic appliances and equipment – Over the last two decades there have been a number
Drug control 685 of hybrid public-private partnership initiatives in
Specialized medical services – Pakistan, in which the government is not the financier
General hospital services 148 072
of services but actually the recipient of financial
and technical support provided by NGOs to poorly
District headquarters hospital 157
functioning government primary health centres.
Tehsil headquarters hospital 123 There have also been instances of voucher schemes
Basic health units/dispensaries/clinics 317 involving the public and private sector primary care
Special hospital services 566 providers. The largest scheme has been for family
planning vouchers from private providers, while
Mother and child health 216
more small-scale schemes for maternal and newborn
Nursing and convalescent home services 532
health services have also been implemented
Antimalarial 551 involving both public and private providers.
Nutrition and other hygiene programmes –
Social protection schemes are fragmented and
Tuberculosis 53
not leveraged to the PHC services. Social security
Chemical examiner and laboratories 439 services exist but are confined to formal government
Expanded Programme of Immunization 131 sector employees with little coverage of the total
Other (health facilities and preventive 5 340
population, and are predominantly aimed at curative
measures) hospital services. The Benazir Income Support
Other categories Programme is one of the world’s largest cash transfer
Administration 21 912
programmes and has a scientific targeting system for
poor households. However, PHC schemes, including
Professional/technical universities/colleges/ 9 043
institutes use of soft conditionalities for immunization or
Secretariat/policy/curriculum 254
antenatal care, have not been introduced so far.
Most recently, the government has launched the
Social welfare measures 3 902
Prime Minister’s Programme for National Health
Total 217 813 Insurance. This involves social protection for hospital-
based tertiary and secondary care services, but it is
not linked to gatekeeping at the primary care level.
6.2 Financing mechanisms However, the programme is fully subsidized by the
government and there is no premium pooling;
The government has traditionally operated as
hence, the basis for this serving as an alternative
both the financier and provider of care in the
mode of financing is questionable.
public sector. However, since the 2000s there has
been a proliferation of both large- and small-scale
purchasing agreements with semigovernmental
agencies and the private sector. Contracting-out

12
6.3 Fiscal flows to support primary Figure 3. Government health expenditure as %
of provincial government expenditure
health care
In Pakistan a single-line budgetary transfer is made 2009-10
to the provinces from the federal divisible pool of 6 6.9 8.2 8.9
tax revenues. Decisions about allocations to the
health sector and other competing sectors, such 2010-11
as education, food, irrigation, agriculture and social 6 8.2 8.5 9.3
protection, are made by the provinces themselves.
Following devolution, the percentage share of the 2011-12
provincial budget spent on health has risen in all the 7.4 8.9 9.5 10.9
provinces, accompanied by greater policy ownership
for health (Figure 3). 2012-13
5.1 7.5 10.2 11.2
Additionally, the federal government has been
contributing partial support to public health
preventive programmes, construction and 2013-14
operational running support to certain tertiary 8.5 9.1 11.3 11.5
health care facilities in the provinces, and drugs,
contraceptives and vaccines, which amounts to 15%
Punjab Sindh Khyber Pakhtunkhwa Balochistan
of total government health spending. Following
devolution federal government support is being Source: Provincial civil accounts.
phased out, with provinces required to take support
for preventive programmes into their own budgets.
Delayed releases of federal support and inadequate 6.4 Integration of financing decisions
release of funds have been chronic issues and with primary care decisions
have worsened after devolution, contributing to
Pakistan has two segments for allocating budgets
underachievement of preventive health care targets
and hence two set-ups for annual budgetary
in vertical programmes. Similarly, delays in release of
planning. The recurrent budget is allocated to
lady health worker salaries at the federal level have
operational expenses of the health system and,
resulted in frequent strikes by lady health workers.
since it is part of the regular budget, its continuity
District governments are important financial is ensured with inflation-adjusted increments added
intermediaries, as 60% of the total health expenditure routinely every year. The development budget is
is accounted for in district budgets. The funding flow used for new health care initiatives and funding is
comes from the provinces, with salaries directly therefore time bound and short lived. Operational
arriving into employees’ accounts. Vaccines for the and development budgets are formulated and
Expanded Programme on Immunization, kits for the approved by the provinces, while on a parallel basis
Lady Health Worker Programme, and supplies for the federal government formulates its development
other preventive programmes are directly supplied and recurrent budget for federal support to the
to the districts, while medicines are partly purchased federal administration regions – Islamabad, Azad
by the provinces and partly by the district, based Jammu and Kashmir, Gilgit-Baltistan, and the
on preapproved tenders. Hence, while the district is Federally Administered Tribal Areas – and for limited
the largest consumer of the budget, it only partially support to the provinces.
manages its budget, while the rest is controlled by
the province.

13
Planning for the recurrent and developmental are being restructured in line with the provincial
activities has been on an ad hoc basis, and has health sector strategies, which provide support for
not been aligned with signed international health more effective and primary care-oriented systems.
treaties, national policies and planning for primary However, budgets have only been partially adjusted
and preventive health care. Development funding in two provinces, while in two others the budgets are
is mainly allotted to visible infrastructure schemes, yet to catch up with provincial planning.
such as establishment of medical colleges, tertiary
International development partners continue to
hospitals or specialty care centres, such as burns
play a significant role in Pakistan’s health context,
or cardiac centres. Allocation to primary care is low
particularly for PHC, population control and
and is mainly targeted towards construction of more
undernutrition. Their main contribution has been
health care facilities rather than demarcation of
in influencing policy and programming, rather
funding for outreach activities, behavioural change,
than the actual value of foreign aid, which averages
monitoring, or governance initiatives.
2%. Development partners have been the major
Vertical programmes – even those started in advocates of Pakistan’s signing of international
the 1970s – have continued to exist, and are health agreements, and have provided support for
extended on development budgets rather than technically assisted and funded vertical programmes
being incorporated into the recurrent budget. The on polio eradication, maternal, newborn and child
recurrent budgets principally comprise salaries health, population control, HIV/AIDS, undernutrition,
(76%), while the remaining share is for items such and more recently routine immunization, as well as
as medicines, supplies, and supervision (Figure 4). large donor-funded projects on PHC and service
Meagre amounts are allocated at the provincial level delivery innovations. United Nations agencies have
for planning, governance, training, monitoring and particularly played a role in standard setting and in
support systems, and at the district level for outreach supporting the Essential Medicines Programme.
support, behavioural change, and field supervision.
Following devolution, the provincial budgets
Figure 4. Recurrent expenditure: Basic health units and rural health centres in Pakistan
Typical Financing of Basic Health Unit Typical Financing of Rural Health Centre
Salaries Salaries
64% 78%
Medicines and supplies Medicines and supplies

7% 4%
Immunization Immunization
19% 10%
Operating expenditure Operating expenditure

10% 10%
Source: Technical Resource Facility, Minimum health services delivery package, 2012 (10).

14
While donors have been the most powerful underfunded. Donor support in Pakistan has been
supporters of primary care in Pakistan, they have mainly routed to projects on the development
also been criticized for verticalization of primary budgets, with donors typically bearing up to 80% of
care activities as opposed to taking an integrative expenditure with much smaller amounts provided
approach. The type of support has often involved by the government. Financing modalities have
short-term interventions such as provision of vaccines therefore mostly involved project-based approaches
and contraceptives or service delivery through rather than use of aid conditionalities, sectorwide
international NGOs, which has wrapped up at the arrangements and performance-based budgetary
conclusion of projects with little investment in policy support to major ongoing government programmes.
or advisory support, technical assistance, or capacity- In the post-devolution context, donor support has
building for structural reforms and institutional expanded towards technical assistance of provincial
strengthening of PHC. Regulation of PHC, including governments for primary care reforms in addition to
the private sector, human resources planning and funding of separate service delivery projects.
management, financial efficiency, availability and
Table 3 presents information on health spending
quality of essential medicines, and independent
according to a range of indicators.
monitoring and evaluation, continues to be critically
Table 3. Health spending and utilization

Indicator Figures Sources of information
Total health expenditure as proportion of GDP 2.8% Pakistan National Health Accounts 2011–12 (9)
Government health expenditure as proportion of GDP 1% Pakistan National Health Accounts 2011–12
Public expenditure on health as proportion of total health expenditure 36.8% Pakistan National Health Accounts 2011–12
Out-of-pocket payments as proportion of total health expenditure 54.9% Pakistan National Health Accounts 2011–12
Voluntary health insurance as proportion of total health expenditure 0.2% World Bank (11)
Proportion of households experiencing catastrophic health expenditure 5% Household Integrated Economic Survey 2011–12 (12)
Proportion of population consulting specific sectors for general health Pakistan Social and Living Standards Measurement
consultations: Survey 2008–09 (13)
Private sector 71%
Public sector 21%
Homeopathy/hakeems 4%

15
7. Service organization
7.1 Governmental and semi- to 82 000 population in Karachi (14). Consequently,
the tertiary hospitals deal with the primary care
governmental PHC provision
needs of the population, resulting in overcrowding
The governmental system provides the largest and lengthy waiting periods.
network of primary care services in Pakistan,
including both curative and preventive care, offered The PHC tier in the government system comprises
through a network of first-level care facilities and the following:
outreach health workers. Since the 1970s there has • Preventive and curative services through
been a dedicated expansion in the government government first-level health care
network of primary care facilities in the rural areas facilities. These include civil dispensaries,
of Pakistan, with one basic health unit per 10 000 maternal and child health centres, sub‑health
population and one rural health centre per 20 000 centres, basic health units and rural health centres
population. Despite an expansive system in rural (Table 4). Referral support is provided by secondary
areas, the government PHC system has struggled in care centres such as tehsil headquarters hospitals,
terms of functionality and utilization. Low population civil hospitals, and district headquarters hospitals,
density and the scattered location of villages in the and further by teaching hospitals located in major
rural areas of at least three of the four provinces – urban centres.
Balochistan, Khyber Pakhtunkhwa and Sindh – have • Outreach-based Community Health
also contributed to low utilization. Paradoxically the Worker Programme. This includes services
urban areas are extremely thin in terms of primary provided by lady health workers and community
care facilities, with a ratio of one first-level care facility midwives.
Table 4. Health facilities by type
Number of health facilities by type

Province/region
District headquarters Tehsil headquarters/ Rural health Basic health Total
hospitals civil hospitals centres units
Azad Jammu and Kashmir 6 12 34 208 260
Balochistan 27 10 82 549 668
Federally Administered Tribal Areas 4 14 9 174 201
Gilgit-Baltistan 5 27 2 15 49
Khyber Pakhtunkhwa 21 77 90 822 1010
Punjab 34 84 291 2454 2863
Sindh 11 56 130 774 970
Total 108 280 638 4996 6021
Source: Health facility assessment (15).

16
• Vertical preventive programmes for 7.2 Private sector
specific public health concerns. These
The Pakistani private health sector is believed to
currently comprise the following vertical
provide services to almost 71% of the population
programmes:
(16). The private sector dominates provision of
–– Expanded Programme on Immunization
primary and secondary care services, while the
–– Prime Minister’s Programme for Prevention
public sector, despite its large primary care network,
and Control of Hepatitis
is the main source of tertiary care for the poor. The
–– Roll Back Malaria
private sector at the PHC level includes general
–– National Programme for Family Planning and
practitioners ranging from doctors, hakeems (3%),
Primary Health Care
homeopathy practitioners (1%) and ayurvedic clinics
–– Lady Health Worker Programme
to maternity homes and traditional birth attendants.
–– Enhanced HIV/AIDS Control Programme
The private health sector mainly comprises general
–– National Tuberculosis Control Programme
practitioners with individual practices, and has
(supported by Strengthening National
largely emerged and grown in capacity during the
Tuberculosis Control Programme by Ensuring
last three decades. There are also hospitals, private
Uninterrupted Drug Supplies)
clinics, maternity homes, laboratories, homeopathic
–– National Programme for Prevention and
clinics and ayurvedic medicine outlets. Many of
Control of Avian and Pandemic Influenza
the private practices are operated by unlicensed
–– Maternal, Neonatal and Child Health
providers. Table 5 provides data on sources of care in
Programme
Pakistan, and Figure 5 compares private health sector
–– National Programme for Prevention and
utilization in Pakistan with that of other countries in
Control of Blindness
the Eastern Mediterranean Region.
–– Improvement of Nutrition through Primary
Health Care.
Parastatal institutions also make an important

contribution to service provision. The armed Table 5. Sources of care in Pakistan (%)
forces of Pakistan have a network of primary and
Indicator Source of care %
secondary health care services in the remotest parts
Antenatal care Government hospital/clinic 30
of Pakistan. These units serve the civilian sections
of the population on a fee-for-service basis, while Private hospital/clinic 51
providing free-of-cost services to the armed forces, Traditional care providers 19

and are among the most utilized service providers Delivery Government hospital/clinic 12
in areas where they are based. There are also (birth care)
Private hospital/clinic 29
semigovernmental and corporate sector health
Home 59
care units provide PHC services to their employees,
mostly through services provided at outpatient Private doctor –
departments of either self-owned hospitals or the Traditional care provider –

employees’ social security network of facilities, or No care –
through purchase from the private sector.
General health Public health care providers 22
consultation
(all age groups) Private health care providers 71
Traditional health care providers 3
Chemist/pharmacy 4
Source: Pakistan Social and Living Standards Measurement Survey 2010–11 (16).

17
In addition, Pakistan has a vibrant and rapidly
expanding non-profit sector funded primarily
through Zakat contributions and philanthropic funds
from citizens and corporate organizations. Most
of these have traditionally invested in large charity
hospitals in urban areas, and are heavily utilized by
the poor for PHC provided through hospital-based
services. However, there has been a recent expansion
in PHC clinics by non-profit organizations mainly
through public-private partnerships, whereby non-
profit organizations have adopted government
clinics for services strengthening in both urban and
rural areas. There has been a growth in provision by
NGOs of humanitarian assistance in disaster areas,
including for those affected by the earthquake of
2005 and the floods of 2010 and 2011. A number of
large international NGOs funded by development
partners are active in primary care service delivery,
and are mainly involved in providing technical
support to government or in providing services
through the existing government network of health
facilities.
Figure 5. Comparison of private health sector

utilization in Eastern Mediterranean Region
countries
Bahrain 5%
Oman 5%
Iran 20%
Syria 22%
Yemen 38%
Saudi Arabia 40%
Jordan 40%
Iraq 45%
Pakistan 77%
Egypt 81%
Lebanon 85%
Overall Private Sector Utilization
Source: Hafeez A (17).

18
8. Human resources for health
Pakistan has an estimated 0.82 physicians, 0.57 nurses Table 6. Human resources for health in Pakistan:
and midwives, and 0.06 community health workers numbers in selected cadres
per 1000 population (Figure 6). There are 160 289 Human resource cadre Registered
registered doctors, 12 544 dentists, 82 119 nurses
Doctors 160 289
and around 100 000 community health workers in
Pakistan (Table 6). Pakistan is also producing certified Dentists 12 544
family physicians, though these are mostly in private Nurses 82 119

practice in urban areas, as the government as yet has Pharmacists 32 511
not established a cadre of family physicians absorbed Lady health visitors 13 678
within its primary care systems.
Registered midwives 29 000
The doctor–nurse ratio continues to be greater Community health workers 100 000
than 1, with fewer nurses produced than doctors,
Sources: WHO Global Code of Practice implementation strategy report (19);
and reportedly high outmigration of nurses. There Pakistan Economic Survey 2013–14 (20).
is also a shortage of allied health professionals;
for example, there is 0.9 pharmacists per 100 000
population in Pakistan, far below the recommended the private and government health sector in rural
ratio of 1 pharmacist per 2000 population. However, areas facing shortages of licensed practitioners. These
policy emphasis has largely been on expansion of urban–rural discrepancies are particularly high for
the number of medical colleges, which has grown doctors, with 14.5 physicians per 10 000 population
exponentially from two in 1947 to 88 in 2012 (18). in urban areas, compared to 7.6 in rural areas. The
open merit policy of medical colleges, introduced
There is skewing of the health workforce, particularly
during the 2000s, has exacerbated shortages of
doctors and nurses, towards urban areas, with both
Figure 6. Human resources for health in Pakistan: ratio of workforce to population
Per 1000 population
0.06
0.57 0.82
1.45 1.45 1.05
Total available Total required

workforce workforce
(1.45) (2.5)
Community Nurses and Physicians
Health Midwives
Workers

19
doctors in rural areas, as female graduates do not Figure 7. Urban–rural distribution of human
enter service or avoid rural postings. There is less resources for health, Pakistan
discrepancy in the distribution of midwives, but
again there is a higher urban concentration, with Density in 10,000 population
3.6 midwives to 10 000 population in urban areas
compared to 2.9 in rural areas (Figure 7).
The workforce at government first-level care facilities Physicians
comprises a male or female medical officer (medical
doctor), lady health visitor, dispenser, Expanded
Programme on Immunization technician, senior
14.5 Urban
or junior PHC technician, female and male medical
technician, and, at some service points, malaria
technician in addition to auxiliary staff. Outreach 3.6 Rural
services that are attached to basic health units
are provided through the lady health workers,
community midwives and vaccinators. Dual practice
is allowed by government rules, and most doctors Nurses and midwives
and paramedics maintain private practices in addition
to government jobs, which has affected attendance
7.6 Urban
of patients at government primary health centres.
The lady health workers are female outreach workers
from within the community who have up to middle 2.9 Rural
school education. They are assigned to cover a
population of 1000 to 1500. Total lady health worker
Source: World Health Organization
coverage is less than 50% of the target population,
with the more remote and disadvantaged areas
reaming uncovered due to the lack of eligible both purely private practitioners and those having
community-based females. They were initially dual employment, including government health staff
community representatives paid through a stipend, engaged in dual practice, while in the rural areas the
but they have now been regularized as government workforce predominantly comprises government
health workers by the Supreme Court of Pakistan. health staff. There are reportedly high levels of
Community-based midwives having 18 months “quackery” with dispensers, lady health visitors and
of training have recently been deployed to cover a midwives operating as licensed doctors in both
population of 5000 for skilled birth attendance. They urban low-income areas and rural remote areas.
operate on a private practice model with a monthly Homeopathy and hikmat are legally allowed to
stipend and birthing stations to support their practice. operate as alternative care practices. These mostly
The community-based midwives are intended as a take the form of individual practices rather than
gradual replacement for traditional birth attendants. dedicated hospitals. However, general consultation
Pakistan has a pluralistic provision of health care. from traditional care providers is only 3% of total
The private sector comprises 35% of all physicians care (16), and most clients utilize these providers
and 17% of hospital beds in the country. General in addition to allopathic care. There are as yet no
practitioner clinics are the main source of PHC. The policies or plans to integrate alternative care into
private sector workforce in urban areas comprises mainstream health care provision.

20
9. Planning and implementation for PHC
9.1 Stewardship have struggled for government ownership and
continuity beyond project life.
Pakistan, in its 68-year history, has experienced one
approved National Health Policy passed through Following devolution, provinces have been faced
Parliament (1990), two National Health Policies with increased responsibilities and the need
announced and approved by the ministerial Cabinet for a sectorwide strategic direction, and have
(1997, 2001) and one draft policy of 2010. None consequently developed respective provincial health
of the policies was translated into operational sector strategies. Development partners assisted with
planning, targets were overambitious and direction linking the strategies to the respective evidence base
tended to be vague. In recent years a National of each province, and consequently large sections
Strategic Framework on Maternal and Neonatal of the strategies are devoted to primary care. All
Health has been developed, along with a National provinces have approved strategies in place and in
Nutrition Strategy and National Action Plan for three provinces have been translated into costed,
Noncommunicable Diseases, but these have not medium-term operational plans. These have been
been integrated into combined action plans. Parallel partially implemented, with varying pace in different
to the sporadic health policies has been a parallel provinces.
process of five-year development plans across all
The provincial ministries have also undergone some
sectors, including health. This has been a more
level of restructuring to respond to new planning
regular process as it is linked to annual development
and oversight needs, though institutional capacity
budgets and approval of projects for different sectors.
is uneven. Health sector reform units are in place
The PHC sector has lacked a policy strategic for strategy implementation in at least three of the
direction, and PHC planning has usually followed a four provinces to assist with sector strategies, plans
project mode, shaped by the project documents of and reform initiatives. Public-private partnership
different vertical programmes, government-funded nodes have also been established in two provinces
primary care projects, and donor-funded primary to undertake contracting-out reforms. Regulatory
care projects. Key government-initiated PHC projects commissions have been established in at least two
have included the Population Welfare Programme, provinces and notified in the third to regulate quality
Rural Health Centre Scheme, School Health Services of health services across the public and private
Programme, Expanded Programme on Immunization sectors. A health management cadre has been
and Lady Health Worker Programme, and these constituted in one province to fill programmatic and
have successfully been transitioned from the managerial posts at provincial and district levels,
project mode of development budgets to sustained while in another province a wide-scale management
financing in the recurrent budget. Donors have been training initiative has started for those holding posts
important instigators and funders of PHC projects, at middle to senior levels.
and key initiatives have included the Social Action
Table 7 summarizes key policy and programmatic
Programme (1990s), Family Health Project (1990s),
developments in Pakistan related to PHC.
HIV/AIDS project (2003), Pakistan Initiative for
Mothers and Newborns (2004), Maternal, Neonatal
and Child Health Programme (2008-ongoing), and
Nutrition Project (2015-ongoing). However, these

21
Table 7. Policy and programmatic initiatives for 9.3 Recent innovations for PHC
PHC in Pakistan
There have been recent planning innovations in the
Year Initiative last decade to improve utilization of PHC facilities,
1961 Rural Health Centres Scheme staff attendance, and service delivery integration.
1976 School Health Services Programme These are summarized in the following subsections.
1982 Expanded Programme of Immunization
9.3.1 Human resources management
1990 Social Action Programme (primary care targets)
While the government has the largest network
1993 Family Health Project (management and capacity of PHC facilities, it is constrained by several
building)
issues affecting human resources management.
1994 Lady Health Workers Programme
There are staff vacancies in rural areas as well as
1998 Roll Back Malaria Partnership frequent absenteeism, and political patronage over
2000 Tuberculosis Treatment Programme appointments and postings has adversely affected
2003 Enhanced HIV Programme staff attendance. Administrative control over staff
2005 Peoples Primary Health Care Initiative (contracting out
appointments, postings and suspension is largely
basic health units) centralized at province level, while district health
2008 Community Midwifery Programme offices, though responsible for staff monitoring, have
2014 Nutrition Programme
less space for disciplinary action. The career pathway
is based on seniority rather than performance-
oriented structural mechanisms, and promotions
are slow moving and centralized. These factors
9.2 Challenges
also constrain motivation for sustained good
The frequent turnover of leadership staff at provincial performance.
and district levels has affected ownership and
continuity of PHC initiatives, especially in the post- There have been some recent innovations to improve
devolution period. Moreover, with loosening of the staff attendance and performance. Outsourcing
tight federal verticality, planning and implementation the management of basic health units in all four
in the provinces has become vulnerable to political provinces as part of the People’s Primary Healthcare
interference in terms of preference for visible Initiative (PPHI) has resulted in visible improvement
infrastructure projects, as well as with regard to in staff attendance. One province (Khyber
staff postings, with greater vulnerability in some Pakhtunkhwa) has recently imitated a system of
provinces than in others. Another ongoing challenge salary remuneration based on remote postings and
is adjustment of budgets – historically dominated performance to support staff availability in remote
by tertiary schemes – in line with the PHC strategic rural areas. Another province (Punjab) has started
direction of the sector strategies. Despite a visible real-time monitoring of staff attendance through
growth in provincial spending going to health, mobile phones used by third-party monitors and
provinces are yet to significantly increase recurrent feeding of data into a district balance scorecard.
budgets for the PHC network of facilities, such However, these are fragmented initiatives and lack a
as for medicines, supplies, communication, and sustained staff administration strategy.
field supervision. Similarly, there has not been
9.3.2 Public-private partnership
a move to provide financing for the preventive
health programmes, and due to low ownership of In Pakistan, an extensive contracting-out initiative –
these programmes there is dependency on federal the PPHI – was started in the mid-2000s, whereby
government or donor support. the management of 2490 basic health units – 569

22
in Khyber Pakhtunkhwa, 554 in Balochistan, 844 9.3.3 Service integration
in Punjab, and 553 in Sindh province – have been
Following devolution there have been attempts to
contracted out to a non-governmental organization
decrease the fragmentation of preventive health
(21). This is one of the world’s largest contracting-
services. Two the provinces have integrated the
out initiatives. The underlying purpose is to improve
vertical programmes to improve financial and
health facility utilization and the quality of primary
programmatic efficiency. However, the other two
care facilities through stronger management and
provinces, while having approved integration in their
accountability. A management contract has been
provincial health sector strategies, are yet to make a
in effect transferring the budget and administrative
move towards integration.
control from the provincial health departments to
a government-funded NGO comprising retired civil Another planning reform has been the development
servants. and approval of essential packages of health
services and minimum service delivery standards
The results of this have been mixed, with a significant
in all provinces. These provide the set of services
increase in outpatient volume but little improvement
and accompanying technologies and medicines
in preventive health care targets. More recently,
to be available at PHC level across the public and
following devolution, contracting out has been
private health sectors. However, these are yet to
extended to rural health centres and secondary
be linked with public sector budgets, contracting-
hospitals in remote disadvantaged areas in at least
out arrangements and private sector regulatory
two of the provinces but has followed a competitive
mechanisms.
bidding process drawing in different NGOs and with
introduction of performance targets.

23
10. Health information systems
Government primary and secondary facilities have of workers that it employs. Comprehensive disease
a well-established District Health Information surveillance is only limited to polio, while an early
System (DHIS) designed with multidonor support warning system for priority communicable diseases,
and reporting every month on a standardized set which was earlier put in place with support from
of indicators. These include 78 indicators inclusive the World Health Organization (WHO), has not been
of service utilization targets and statistics, stock-out, taken over with government support.
capital assets and priority disease cases. It is now
The presence of a multiple vertical programme MIS,
established in more than 125 districts out of the 140
in addition to the DHIS, has resulted in duplicative
districts in the country (Table 8). Monthly reporting
efforts. This proliferation of multiple MIS systems has
is computerized at the district level and transmitted
reduced the use of the DHIS for decision-making
online to performance dashboards set up at the
and strategic planning. Another issue is the variable
provincial and federal health ministries.
quality and reliability of the data of the main DHIS,
Outreach community-based information is provided further reducing its usefulness for decision-makers.
through the Lady Health Worker Programme,
There have recently been innovations to improve
including reporting for households registered for
data quality. Independent m-health-based
contraceptive use, antenatal care, growth monitoring,
monitoring has been initiated by the government
health education and facility referrals. In addition there
in one province for providing verifiable data on
are the MIS of the main vertical programmes (section
service statistics, medicines and human resources
7.1), including HIV/AIDS, tuberculosis, Expanded
availability. Additionally, a computerized logistics
Programme on Immunization, malaria, dengue, and
management system has been initiated for vaccines
maternal, newborn and child health. There is also
and contraceptives in several districts of Pakistan,
the MIS of a separate verticalized polio eradication
though this has not as yet been extended to essential
programme. Furthermore, there is the MIS of the
medicines. Performance management dashboards,
Department of Population and Welfare reporting
recently set up in all four provinces and the federal
on contraceptive use at health facilities controlled
capital, are now providing to decision-makers quick
by the department and through the separate cadre
Table 8. Health information system: national implementation
DHIS implementation Districts with DHIS

Provinces Total districts (no.) reporting (Dec. 2015)
Punjab 36 36 36
Sindh 23 23 23
Khyber Pakhtunkhwa 24 24 24
Balochistan 30 27 27
Azad Jammu and Kashmir 10 10 10
Federally Administered Tribal Areas, Gilgit-Baltistan, 17 8 8

Islamabad Capital Territory
Total 140 128 128

24
online feeds of the DHIS, vertical programme MIS, beyond facility-based MIS, there is still no MIS for
Lady Health Worker Programme MIS, and surveys. human resources and for procurement within the
While health statistics are being increasingly government health system to assist in making
reviewed by policy-makers, the fragmentation of programming decisions for primary care services.
data remains an issue. Moreover, there is no reporting system for Pakistan’s
wide and entrenched private sector. Regulatory
There are also further areas for enhancement
commissions have started working in two of the four
and extension of the primary care MIS. The MIS of
provinces, but minimal reporting indicators for inputs
primary care facilities has yet to integrate some
and services are yet to be worked out for the private
of the public health issues confronting Pakistan,
sector. There is some reporting by the private sector
such as undernutrition, NCDs and mental health.
for a few priority diseases but, due to the absence
There has also been little work to link the MIS of
of a comprehensive disease surveillance system and
health facilities with Pakistan’s computerized vital
registries for NCD cases, reporting is sporadic and
registration system, and 70% of births and 90% of
limited to a few providers.
deaths are not registered in the country. Moving

25
11. Regulation
11.1 Drugs and essential technologies 11.2 Human resources production and
Pakistan has a National Essential Medicines List training
and fairly well developed policy measures and Human resources production decisions are taken
operative guidelines for regulation of essential at the national level, with the consensus of the
medicines. However, gaps exist between policies provinces. The professional councils – the Pakistan
and health system practices. The concept of essential Medical and Dental Council for doctors and dentists,
technology, despite its relevance to PHC, is as yet in and the Pakistan Nursing Council for nurses and
the initial stages. midwives – are responsible for licensing the health
There is a federal Drug Regulatory Authority of professionals produced. They are also responsible
Pakistan for drug industry licensing, drug registration for licensing and regulating the medical and nursing
and pricing, and a comprehensive Drug Act, 1976, schools and regulating medical education. A council
regulates the pharmaceutical sector. However, the for allied health professionals is yet to be established.
profusion in the number of licensed drug products There is no council for alternative medicines, for
raises questions about the tightness of quality example homeopathy and hikmat. Production
controls and very few companies are WHO certified. continues in the absence of defined human resources
targets. Furthermore, existing databases for human
Retail stores and pharmacies are the main outlets resources registration are not frequently updated,
for medicines in the private sector, and due to and it is not known how many health professionals
frequent stock-out at government facilities they produced are actually in the country and in active
are also a frequent source for public sector patients. practice.
Market surveillance is conducted by the provincial
departments of health and involves sampling of Across the public and private sectors, human
drugs on the market. There is presently poor capacity resources capacity is weak for responding to existing
in terms of laboratory support and drug inspectors and emerging primary care needs. Recent policy
to detect counterfeit drugs and to monitor drug initiatives also require strengthening of capacity. For
prices and availability. Surveillance is restricted to example, the recent provincial health sector strategies
drug product sampling, and overlooks availability specify task shifting to overcome staff shortages
and pricing of essential medicines, drug storage, in rural areas. These also endorse the concept of
and drug-dispensing practices. PHC services are essential health service packages to be provided
affected by frequent shortages of essential low- across the public and private sectors. However, the
priced generic drugs on the market due to low profit required revisions to medical, nursing and paramedic
returns for the industry and weak regulatory control curricula for building skills for essential health
by the government (22). services and additionally for task shifting have not as
yet been worked upon by the professional councils.
An Essential Drugs List for primary care facilities This will also require the promotion of community-
governs health service providers in the public sector. based PHC learning in teaching curricula, which is
The Essential Drugs List is not followed in the private currently weak.
sector or in the recent contracting-out arrangements
of the government for its first-level care facilities. Continuing medical education, including in PHC-
Both public and private sectors have weak practices relevant areas, is now offered by a growing number
for drug transportation, storage and dispensing, and of urban-based professional institutes, but is still
are inadequately regulated (17). not a requirement for relicensing. The provincial

26
governments have provincial health service has complete the legislative work to set up a
development centres for ongoing provision of regulatory commission. The work is mainly centred
in-service training to primary care staff but lack a pre- on licensing of government health facilities and is yet
service and in-service training plan and provision to be scaled up to private sector regulation, which is
of necessary resources. Training related to vertical expected to be a more complex task. There is also
preventive programmes is offered on an ad hoc basis, a need for linkage with the essential health service
subject to availability of donor support. Following packages developed by all the provinces and some
devolution, only one province has started pre- movement towards minimum standard setting
service and in-service training, but it is confined to across all the provinces. As yet there is no plan to
the primary doctors and still needs to be extended to regulate pricing of health services.
nursing and allied health staff. There are no systems
in place to provide training and accreditation to the 11.4 Other areas
private sector. Accreditation for primary services has been practised
through voucher schemes in Pakistan. These have
11.3 Health services involved both public and private sector accreditation
Health service delivery, including PHC, is unregulated for maternal vouchers through various donor-
in Pakistan. While this has reportedly given rise to supported projects, including the Norway-Pakistan
extensive “quackery”, the licensed health providers Partnership Initiative and the Pakistan Initiative for
also do not need to register with health ministries Mothers and Newborns. Both were confined to a few
for opening up a practice. There has been some districts and came to an end with project closures.
piecemeal regulation of the primary care sector More recently family planning vouchers have been
through different programmatic initiatives, such introduced for private providers in all four provinces,
as declaring hospitals as “baby friendly” based but there is no nationally extensive coverage.
on breastfeeding promotion, and instigating
There are two recent much larger initiatives also
blood safety initiatives through blood transfusion
involving the purchases of private sector services
authorities.
– the contracting-out scheme started by different
In the post-devolution period, health regulatory provinces and the Prime Minister’s Programme for
commissions have been established in two of the National Health Insurance. Regulatory mechanisms
provinces to regulate health services across the for insurance and public-private partnerships are yet
public and private sectors, while another province to be defined and integrated.

27
12. Outcomes: coverage of and access to essential services
12.1 Coverage Figure 8. Trends in coverage for key health
services
Pakistan’s coverage of primary care services has
been suboptimal and has seen slow progress over PDHS 1990-91
the years. Only one third of pregnant women make 14.1%
four or more visits for antenatal care, and almost half 11.8%
36% 21.8%
of births take place without skilled birth attendance
(Figure 8). There has been a sluggish increase in the
use of contraception over the last two decades with
the current contraceptive prevalence rate at only 35%, PDHS 2006-07
and use of modern methods is even lower at 26%.
Unmet need is high at 20%, signalling lack of access
to contraceptive services. Immunization coverage in 47% 39% 29.6% 28.4%
Pakistan has seen a slow pace of increase and only
54% of children are fully immunized (Figure 8). The
deficits in immunization coverage are reflected in the
continued incidence of endemic polio transmission PDHS 2012-13
and the recent measles and diphtheria outbreaks.
Preventive health interventions for nutrition have
included vitamin A supplementation to children, 62% 54% 36.6% 36.4%
along with polio immunization, iron and folate
provision to mothers through the Lady Health
Worker Programme, and deworming and routine
counselling on infant and young child feeding at
health facilities. Other activities, such as community- ANC4+Visits
based management of acute malnutrition, Skilled Birth Attendance
Contraceptive Prevalence Rate
breastfeeding campaigns, and community advocacy,
Fully Immunized Children aged 12-23 months
have had patchy coverage confined to specific
projects. Vitamin A supplementation has achieved Key: PDHS = Pakistan Demographic and Health Survey.
better results across all provinces compared to other
health activities (Table 9), due largely to effective
horizontal coordination with the federally run polio
immunization programme.

28
Table 9. Mother and child care: micronutrient supplementation, feeding practices, and
undernutrition management
Khyber Balochistan
Interventions Punjab (%) Sindh (%) Pakhtunkhwa Pakistan (%)
(%)
(%)
Exclusive breastfeeding up to 6 months 18.0 10.0 47.0 27.0 13.0
Complementary feeding 6–8 months 49.6 63.2 36.1 48.6 51.8
Handwashing with soap 57.8 56.2 62.3 52.3 57.6
Iron supplement intake 26.3 26.1 19.3 11.4 –
Folic acid intake 22.5 31.3 28.0 17.4 –
Vitamin A supplementation 81.3–91.6 83.7 77.8 72.6 79.1
Deworming 78.1 71.6 87.9 56.5 77.1
Reported use of iodized salt 36.1 39.2 49.0 45.4 39.8
Sources: National Nutrition Survey, Pakistan Demographic and Health Survey, Vitamin A Supplementation Survey, Aga Khan University and M
icronutrient Initiative.
12.2 Uneven service coverage 12.4 Spending on health by income

Significant inequity exists in health spending and groups
service utilization. There remain wide urban–rural Although in Pakistan the share of total health
and interprovincial disparities. For example, coverage expenditure contributed by households is 54%
of four or more antenatal care visits is only by – lower than that of some other low- and middle-
12.3% in Balochistan, compared to 38.5% in Punjab income countries – the household spending is
(2). Similarly, within Punjab there is much lower regressively distributed. The lowest income quintile
utilization in the disadvantaged districts of southern spends 6.6% on health, compared to 1.3% by the
Punjab compared to urban centres. Immunization highest income quintile (Figure 9).
coverage has actually declined over the years in
Sindh and Punjab, while there has been a steady Figure 9. Proportion of health expenditure
increase in Punjab and Khyber Pakhtunkhwa due to from total income (%)
better vertical accountability.
13%
12.3 Income differentials in service Poorest Quintile 23%
access 7%
Health and nutrition coverage, when stratified by 3%

income quintiles, is clearly lower in the poorest 4%
2nd Quintile
income quintiles compared to the richest quintiles
2%
in all four provinces. For example, maternal folate
supplementation is only 7.7% in the lowest income 3%
group in Khyber Pakhtunkhwa compared to 19.3% 3rd Quintile 3.2%
in the highest income quintile. Similarly, more 2%
resourced provinces have better indicators. Table 10
provides coverage data for all provinces. 2%
Richest Quintile 1.5%
1.4%
2005-06 2007-08 2010-11

29
Table 10. Health and nutrition intervention coverage among wealth quintiles in the four provinces
of Pakistan
Wealth quintile
Intervention (% population in quintile covered) Overall
Poorest Poor Middle Rich Richest
Punjab
Antenatal care by skilled health worker (last delivery) 44.6 54.8 65.8 75.9 88.2 56.9
Maternal iron/folate supplements 16.8 19.3 23.5 30.1 39.1 26.3
Exclusive breastfeeding up to 6 months 2.3 5.2 7.2 10.4 12.2 7.6
BCG (card) 19.4 30.2 41.9 45.8 49.6 38.2
Measles vaccination (card) 12.4 19.8 29.8 33.2 37.1 27.0
Vitamin A supplementation 76.4 80.1 81.8 81.9 80.8 80.4
Khyber Pakhtunkhwa
BCG vaccination (card) 26.1 29.8 34.4 45.0 50.8 35.4
Sindh
Balochistan
Source: National Nutrition Survey (6).

30
12.5 Utilization of government PHC Table 11. Basic health unit consumers by
income/wealth quintile
facilities by income groups
PPHI: basic health District department
There have been some attempts to improve access Quintile unit, consumers of health: basic health
(%) unit, consumers (%)
for the poor through recent reforms. Contracting
out of basic health units across all four provinces Lowest 27.6 12.4
of Pakistan has drawn in a higher percentage of 2 23.5 18.9
poor consumers to government primary care 3 20.0 19.9
facilities as compared to those basic health units still
4 15.9 23.9
managed by the government health departments
Highest 13.1 25.0
(Table 11). While in both arrangements free services
are provided, it is possible that, with the existence of Total 100.0 100.0
more functional health services, the poor who were
not accessing care are now using government health
facilities. 12.7 Efficiency
There have been recent efforts to improve the
12.6 Barriers to access efficiency of Pakistan’s PHC system. Efforts at vertical
Disadvantages areas, particularly remote rural areas programme integration and development of
in Pakistan, have seen little or slow change in access essential health service packages have attempted to
to key elements of health coverage. Poorly functional improve the technical efficiency of service delivery
health facilities, formidable distances (especially in by putting in place a single administrative, reporting
Balochistan, Khyber Pakhtunkhwa and Sindh), and structure and pooling budgetary resources. Similarly,
low awareness of preventive services are the main the contracting-out arrangements set up during the
barriers reported by different studies, while cultural last decade are driven by the underlying purpose of
and religious restrictions are less reported (23, 24). increasing health facility utilization, hence improving
Private sector establishments, while reported to be the cost-efficiency of the government primary care
more functional than government health centres, facility network.
involve expense, hence use is limited mainly to
acute conditions in both low-income urban and Health worker efficiency can be further improved.
rural populations. In rural areas the scarcity of health The provincial health departments and population
centres involves the additional expense of transport welfare departments, which are responsible for
to reach private clinics located in district centres, or family planning, continue to operate in isolation,
transiting to more affluent districts that have private with both maintaining a tier of primary care health
health providers (25). facilities, village-based workers and management
staff. Most of the budgets of these departments go
The transportation barrier has generally been on salaries of staff. Departmental integration, or at
overlooked in health sector planning. Clients in least integration at the level of health workers, can
remote districts prefer child birth at home due both reduce costs and provide a wider platform
to high transport costs and the inconvenience of for delivery of family planning services. Within the
travel. The cost of transportation is highly variable health departments there are also different outreach
across districts, with a range of 3000–6000 Pakistani staff that provide services to villages, including the
rupees for availing obstetric care in Sindh’s more lady health workers, community midwives and
disadvantaged districts (26). vaccinators, whose work and reporting is often in
parallel and does not feed into a single plan for the
union councils.

31
There are larger efficiency issues that need to be Table 12. Quality indicators for diabetes
targeted through health sector reforms. Overlaps mellitus management in outpatient settings
between the public and private sectors exist, Indicator % of facilities
particularly for PHC. Contracting of the private sector
Availability of infrastructure
for management agreements is now an established
Physical examination room 46
norm in Pakistan. Purchasing of private sector services
to extend and supplement government gaps in Urine dipstick for glucose test 69
service delivery has as yet not been tried out, and Basic equipment availability
is an important channel for reducing unnecessary Examination table 77
duplication as well as for harnessing the private
Functional glucometer 74
sector towards public health goals.
Fundoscope 31
12.8 Quality of private health sector in Weight machine 93
Pakistan Availability of essential drugs
Pakistan is one of the countries with the highest Availability of WHO recommended oral 57
hypoglycaemic drugs
utilization of the private sector (71%) in the Eastern
Mediterranean Region. The private sector is mostly Availability of WHO recommended insulin 57
injections
utilized for primary and secondary care services,
Process of care counselling for diabetes patients
while government tertiary hospitals still dominate
in the provision of affordable and functional hospital Health education on lifestyle, diet provided to 100
% of patients
care. The high level of primary care utilization is
Percentage of patients received IEC material on 96
due to a combination of factors, including staff diabetes mellitus
and drug shortages at government health facilities, Patient satisfaction
confinement of government clinics to day hours,
Percentage of patients who are satisfied with 99
and allowance of dual practice to government staff care they received at facility
whereby they can divert patients to private clinics. Percentage of patients who are satisfied with 64
It is difficult to separate licensed from non-licensed staff attitude
practitioners in the private sector due to lack of Source: Hafeez A (17).
regulatory systems. Data on the quality of health care
services at private sector establishments are patchy.
Private practitioners are reported to have good 12.9 Continuum of care
availability of basic equipment, though the drugs Pakistan does not have a health system that binds
dispensed often do not follow those recommended users to a single point of contact – government
by WHO protocols and the process of care is uneven facilities are free of cost and can be accessed in any
(27). The average number of medications prescribed district or city. Furthermore, patients often bypass
in Pakistan is higher than for many other low- and primary care facilities to access the outpatient
middle-income countries, prescription practices departments of large government hospitals
frequently do not follow standard recommended for routine primary care services, as there is no
therapies, and there is high use of injectables (28), gatekeeping for hospital access. Although there is an
with these practices more prevalent in the private elaborate network of primary, secondary and tertiary
sector (22, 29). Table 12 shows findings from a facilities, so far a referral system that filters patients
four-district WHO cross-sectional survey of quality from primary to hospital care and back-referral
parameters in outpatient clinics of licensed providers to primary care for follow-up and rehabilitation
using diabetes mellitus as a tracer lens (17). does not presently exist. The current organization

32
of the health MIS in the government sector also 12.10 Health co-production
limits continuity of care and is organized for health
In Pakistan there have been various attempts
programming decisions. There are no case notes and
to initiate community inclusion in health care
patient folders, with information recorded in registers
production. District health management teams
for tallying patient numbers, nor is there a system of
were formed in the 1990s for inclusion of elected
back-referral information.
representatives in decision-making on health care.
In the private sector, health services are largely These however were not fully operationalized,
paid for through out-of-pocket payments rather though they have recently been revived; and there
than through prepaid insurance arrangements tied is less representation of civil society. Hospital boards
to certain accredited providers. Hence patients with citizens’ representation were set up at secondary
freely hop from one general practitioner to another care hospitals, but again were not continued beyond
or directly access specialist services depending the period of the project. Village health committees
on ability to pay. The concept of certified family are in place in several union councils to oversee
practitioners providing a single source of care the work of lady health workers, but many are not
for the needs of different age groups has not functional.
taken hold in Pakistan due to competition from
Health service implementation is therefore
general practitioners and specialists, and lack of an
dominated by choices made by health managers
established government cadre. Although there is a
and providers. There is only one consumer protection
Family Practice Association of Pakistan, the number
network, but that mainly targets the safety of
of certified family practitioners is few, with high
products and drugs. There is currently little on the
attrition to the Gulf countries.
ground in terms of forums for local choices on
Lady health workers remain the single point of health care, consumer rights awareness and medical
contact for low-income communities, and offer grievance platforms.
a platform for continuity of care. The Lady Health
Worker Programme package of services has
expanded over the years from initially contraceptive
provision and maternal and child health awareness
to involvement with polio, communicable diseases
and undernutrition. However, with an expanding
package of services, their ability to provide quality
services is becoming questionable. Hence lady
health workers tend to provide time to services that
are vertically accountable and are incentivized, such
as polio, with decreasing attention to their service
package. Moreover, more remote and disadvantaged
areas do not have Lady Health Worker Programme
coverage.

33
13. Pathways of success and failure in primary health care
This section includes two notable pathways of services, including federal vertical programmes, were
success and two notable pathways that led to barriers delegated to the provinces.
to improvement of PHC services. The following
Preceding the devolution was the increase in fiscal
elements of inquiry have been presented:
space and financial autonomy provided by the
• Decentralization of decisions for health care National Finance Commission Award, 2011. The
management and services: success National Finance Commission Award is a revenue
• Type and extent of purchasing arrangements: distribution formula between the federation and the
success provinces for the revenues collected by the federal
• Government capacity to manage partnership government for a period of five years. The seventh
agreements: barrier National Finance Commission Award was agreed
• Integration of vertical programme structures: between the federal and provincial governments
barrier. after a long-awaited period of 14 years, and increased
the fiscal space of the provinces by slashing the
13.1 Decentralization of decisions for federal share of tax revenues from the 55–62% given
health care management and services in the previous awards to 44% in the new award, with
56% given to the provinces (30). It also provided an
13.1.1 Structure equity-based formula for distribution of resources to
Devolution of health to the provinces in Pakistan the less populated provinces based on development
resulted in major structural changes in governance, indicators and security challenges.
providing increased fiscal, planning and
administrative space. The impact is still unfolding and 13.1.2 Stewardship and planning
can be measured in the long term, though outcomes Following devolution the provincial governments,
in terms of stewardship, financing and monitoring which had traditionally followed a federally
are already visible. Two functions are explored here driven and tightly bound planning process, were
– stewardship and planning, along with financing to confronted with a stewardship challenge. Although
see how these have been affected by devolution. the devolution was announced in 2010 there was no
action by the Federal Ministry of Health for transition
The 18th Amendment to the Constitution of Pakistan
until its abolishment in June 2011. During this period
devolved the powers of 21 sectors, including health,
no plan was developed for handing over resources,
from federal to provincial level. Few functions related
prioritizing key issues and responses, and demarcation
to health were left with the federal level, and an
of responsibilities within provincial structures. Hence
Interprovincial Concurrent List was formulated with
provinces were suddenly confronted with a large
consensus listing of international commitments,
increase in responsibilities while lacking the structures
drug licensing, registration and pricing functions,
and capacity to take this forward.
export and import of goods and services, and
professional councils, such as the Pakistan Medical “The devolution was thrown to the provinces with
and Dental Council, Nursing Council and Pharmacy a single stroke of pen; the provinces had neither
Council as federal functions. Notably, planning, the capacity nor prepared to take this up – this was
sector stewardship, priority setting, financing, when a decision was taken that province specific
services regulation, and management of health care health sector strategies need to be developed.”
(Key informant)

34
Following devolution all the provinces, assisted In two of the provinces – Sindh and Khyber
by development partners, immediately started on Pakhtunkhwa – the planning process has now
development of a sectorwide health strategy to span moved forward to the district level with development
a long-term 8–10-year period. The province-specific of district health plans. Much will now depend upon
health sector strategies were developed through whether the district health plans get translated into
an evidence-based consultative process involving annual budgets and become the benchmarks for
the private sector, NGOs, experts and development monitoring and accountability of the districts.
partners, and were preceded by provincial health
“The devolution of 2011 brought empowerment
sector situation analysis exercises. All provinces
to the provinces, for which they had contested
have since developed their health sector strategies
for decades, but will it bring a change, is yet to be
outlining the major outcomes, outputs, strategies and
seen.” (Senior bureaucrat)
reforms, with large emphasis on PHC interventions.
Three of the provinces also now have a 3–4-year Hence, while devolution has occurred in a haphazard
costed implementation plan with a results framework and unplanned way, it has resulted in provincial
for implementation of the strategies. The provinces and district-level empowerment in planning and
have also introduced a number of policy acts administration, and has led to financial allocation in
exercising their stewardship role and in support of accordance with evidence-based needs.
the health sector strategies, including acts on public-
private partnerships, health services regulation, and 13.1.3 Health spending
hospital autonomy. The provincial department in The transfer of fiscal autonomy of social sector
all provinces, except Balochistan, have a policy and spending to provinces has translated into increased
reforms unit, or a public-private partnership unit spending on health by the provinces. The provincial
to take forward the stewardship initiatives. Further share of the budget going to health has increased in
restructuring and capacity-building is an issue that all four provinces (Figure 10.). At the same time the
needs to be addressed. Moreover, the health sector share of health in the federal budget has declined,
strategies now need to be linked with the medium- and is now mainly given towards partial support of
term development and budgetary framework of the the vertical preventive programmes until 2016.
government system in all provinces.
Figure 10. Provincial share of budget to health
Punjab Sindh
2009-10 8.9 2009-10 8.2
2010-11 9.3 2010-11 8.2
2011-12 10.9 2011-12 9.5
2012-13 11.2 2012-13 10.2
2013-14 11.5 2013-14 11.3
Khyber Pakhtunkhwa Balochistan

2009-10 6 2009-10 6.9
2010-11 8.5 2010-11 6
2010-12 8.5 2011-12 7.4
2012-13 5.1 2012-13 7.5
2013-14 9.1 2013-14 8.5

35
An analysis of government pooled budgetary been some increase in funding for the Expanded
allocations from all sources also shows significantly Programme on Immunization and for nutrition
higher health budget allocation to the provinces due to incentivized matching donor support, the
and districts after the 2011 devolution, while the provinces have not moved to take over funding of
federal share shows a decrease over the same period. the vertical programmes, including the large Lady
Federal allocations have declined from 23% of the Health Worker Programme, from the federal level.
total public sector budget in 2008/2009 to 11% As a result of low ownership for preventive care,
in 2012/2013 (Figure 11). The provincial share has there has been preference for continued federal
shown the largest increase from 41% in 2008/2009 support to preventive health programmes. The
to 59% in 2011/2012. The district share of allocations operational budget, which was largely consumed by
has declined after the lapse of the local government salaries, has shown an increased share of spending
ordinance from 32% in 2008/2009 to 25% in on medicines and supplies. However, spending on
2012/2013. governance, monitoring and evaluation, training
and communication continues to be similarly low
Devolution, by providing the requisite financial
as before. Hence devolution, while being successful
and administrative authority, has been successful
in more enhanced health spending, has been less
in equitably increasing spending to health and also
successful in effective spending of financing.
in providing a greater share to the provincial health
system. Further increase in district allocations can 13.2 Type and extent of purchasing
make existing allocations more equitable. arrangements
However, despite an equitable increase in funding, Contracting out has been a popular mechanism in
there has been less change in spending priorities. Pakistan for making organizational changes in the
Health expenditure of the development budget way services are delivered. Two major initiatives of
continues to be dominated by construction work contracting out primary health services in Pakistan
and large tertiary care schemes. While there has are presented here, drawing comparisons for
Figure 11. Consolidated health budget 2008–2013: federal, provincial and district shares (%)
59%
57% 56%
53%
46% 45% 46%

44%
41%
32% 31%
30% 29% 30% 29% 30%
26% 25%
23% 22% 22%
20%
18%
15%
13%
10% 11%
2008-09 2008-09 2009-10 2009-10 2010-11 2010-11 2011-12 2011-12 2012-13

B.E A.E B.E A.E B.E A.E B.E A.E B.E
Federal Provinces Districts

Key: B.E = budget estimate, A.E = actual expenditure.
Source: Technical Resource Facility, budget and expenditure analysis (31).

36
sustainability. Government instigated and designed support from both the elected representatives and
contracting out of primary care facilities has sustained the civil bureaucracy as a means to rectify poor
and expanded, while a smaller-scoped, donor- governance within the government health system.
supported contracting out of maternal, newborn and The initiative met with resistance from the staff of
child health services failed to be sustained. Politics the Department of Health, especially from district
and power have fundamental implications for the health officers, whose budget and administrative
intent, design and implementation of contracting- domain was reduced to secondary care services
out initiatives in Pakistan (32). and outreach-based preventive health services.
Although there were initial delays in the transfer of
13.2.1 People’s Primary Healthcare Initiative administrative control in the districts, higher-level
(2005–present) support meant that it was rolled out successfully.
In Pakistan, an extensive contracting-out initiative With the passage of time, the National Rural Support
– the People’s Primary Healthcare Initiative (PPHI) – Network has been transitioned out of the contractual
is in place whereby the management of 2490 basic agreement and the PPHI has been registered as a new
health units have been contracted out to an NGO. government-funded company comprising serving
The initiative started during the mid-2000s during civil service officers deputed for its management.
the period of district devolution in Rahim Yar Khan Contracts have been extended and management
district of Punjab, when the local district legislature contracts for rural health centres are also being
took exception to the poorly run government provided to the PPHI in some of the provinces. The
primary care facilities. The district office and the PPHI is an example of a home-grown contracting-
provincial health department were considered to out arrangement that has expanded and been
have poor capacity for managing health services and sustained. Key factors were the legislature’s demand
hence with the help of the provincial Planning and for functional primary care facilities and support
Development Department, which is the overarching from Pakistan’s elite civil service, which found an
department across all government departments, opportunity to directly bring health networks under
a unique contractual arrangement was set up. The its management.
management of all the basic health units of the district
was outsourced to a government-funded NGO, the 13.2.2 Donor-funded contracting for
National Rural Support Network, comprising retired maternal, newborn and child health services
civil bureaucrats and a project structure involving civil (2008–2012)
service officers in active service deputed to manage
primary care services. A single-line transfer of the The Norway-Pakistan Partnership Initiative, supported
health facilities’ budget was given to the contracted by the Norwegian Government, introduced
set-up, along with full administrative control for contracting out in Sindh province of Pakistan
programming. Additional funds for administrative specifically for maternal, newborn and child health
costs and monitoring were provided as a special services. The aim was to improve those services
grant from the public sector budget. through results-based financing, and contracting out
was one of the main initiatives supported through this
With the support of the Chief Minister and the mechanism. Funding was provided by the Norwegian
powerful civil administrative bureaucracy, the Government, with the implementing partners being
contracting out of basic health units was extend to the maternal, newborn and child health vertical
10 districts in Punjab and called the Chief Minister’s programme of Sindh and the United Nations
PHC Initiative. It was then rapidly expanded to all Children’s Fund (UNICEF). Funds were channelled
provinces of Pakistan and renamed the People’s to UNICEF for management while the maternal,
Primary Healthcare Initiative (PPHI), with strong newborn and child health programme’s role was

37
technical endorsement and oversight coordination among those who utilized services (33). Facility
with the provincial and district governments. utilization for maternal, newborn and child health
services dropped after withdrawal of project staff,
Contracting out of maternal and child health
cessation of extra supplies, and closure of hands-
services at government primary care facilities was
on monitoring provided by the contracted NGO.
implemented in two districts of Sindh – Shaheed
These changes could not be sustained after contract
Benazirabad and Larkana – over a two-year period.
termination as reliance was on contractual staff and
The contracts were confined only to maternal,
donor-provided top-up funds.
newborn and child health services, in line with
the donor mandate. The bidding drew an ample Confinement of the scope of contracting to maternal,
response from large local NGOs and the contract newborn and child health led to a project-based
was competitively awarded to an NGO consortium. approach rather than institutionalizing organizational
A separate third-party monitoring and evaluation and fund flow changes. There was similarly undue
contract was set up with another firm to inform on reliance on the vertical maternal, newborn and
performance deliverables for financial releases. child health programme, which had little power and
authority over district budgets and administrative
The initiative ran into problems during
set-up. Reliance on donor funds rather than core
implementation. It was difficult to separate the
government funding also led to predictable fold-up
maternal, newborn and child health staff and
of contracting after project closure.
supplies from the general health facility budget, as
the same core team provided all the services at the 13.3 Government capacity to manage
primary care facilities. Budgetary and administrative partnership agreements
control for the contracted-out government health
facilities could not be transferred to the NGO due to PHC services have been contracted out to NGOs
resistance by the district health officers. The maternal, in recent years as an approach to widen health
newborn and child health programme had little service coverage and improve quality, efficiency
administrative control over the districts while the and transparency of health services. Based on
provincial health secretariat having administrative international experience, contracts can and should
leverage over the districts had little ownership of become useful tools to regulate and incentivize the
an initiative perceived to be led by foreign donors provider towards intended targets. For this to happen
and United Nations agencies. Contracting out there needs to be adequate capacity to manage
was hence confined to donor-provided funds, and contracting from its inception, including contract
these were used by the contracted NGOs for hiring design and drawing in competitive providers for
separate contractual staff and supplies rather than contract monitoring and payments (34).
management of existing staff and services, with In Pakistan the largest model of contracting out
funds being allocated to hiring of supplementary of PHC service delivery is the PPHI. Details of this
staff, training, upgrading facilities, and provision of initiative are given in the previous section. The main
extra supplies and equipment. Pay-for-performance purpose behind this initiative was to make the basic
incentives, built into the contracts, were given to all health units more functional and thereby increase
staff regardless of performance. service utilization.
Due to the absence of an endline survey, reliable Third-party evaluation of the PPHI shows higher
estimates of coverage and equitable use are not utilization of contracted basic health units in terms
available, though third-party monitoring results of volume of outpatient attendance. There has
indicate functioning services, upgraded facilities, also been improved cleanliness and maintenance,
staff presence and high levels of client satisfaction higher staff presence, and higher patient satisfaction

38
compared to Department of Health-managed Table 13. Reasons for using basic health units
facilities (Table 13) (21). However, there has not given by those who received services (%)
been an increase in facility-based preventive and PPHI basic District Department
promotive services, such as immunization, family Factor health unit, of Health basic health
consumers (%) unit, consumers (%)
planning, maternity care, and growth monitoring.
Easy access 48.2 86.0
The uneven performance of the PPHI can be related Quality service 44.5 7.8
to weaknesses in the contract management capacity
Reasonable price 5.1 5.5
of the government. According to stakeholders,
Concerned staff 1.7 0.3
the contracts were more a formal requirement to
divest management authority in the new PPHI Suitable hours 0.5 0.3
structure and were not designed as a management Total 100.0 100.0
tool. Moreover, there was no practical experience Source: Martinez et al. (21).
in the government system in how to design and
monitor contract arrangements for services (14).
Procurement experience is mainly confined to drug PPHI activities, due to the extensive decision space
and technology tenders, usually fixed at the lowest- given to them with single-line budget transfers, have
priced bid. often tended to divert from the PHC programming
The PPHI contracts are input based, and lack followed by the government (35). For example, the
detailed specification of a service package and initiative has adopted a cluster approach, rotating
key performance indicators for services (21). There the medical doctors through a cluster of nearby basic
has also been no involvement of the departments health units as opposed to the rule of one doctor per
of health in designing these contracts, which are basic health unit followed in government-managed
handled and developed by the higher levels of facilities. It has also introduced other programming
bureaucracy and approved through the Chief changes, such as ultrasound machines at the basic
Minister’s secretariats. Hence in the absence of tight health unit level (36) and keeping drugs that do not
targets the emphasis continues to be on curative comply with the government’s Essential Drugs List.
care rather than preventive care. Another constraint This has given rise to conflict in the districts, but
is that the contract does not provide administrative due to lack of specification of service packages and
control over preventive care outreach services, and standard operating guidelines in the contract, and
these continue to remain within the district health absence of arbitration channels, there has been a
offices and the vertical programmes. Therefore while lack of resolution of the challenges.
previously the primary health facility in each union Financial transparency also becomes a concern,
council was the pivotal point for microplanning and given the one-line budgetary transfer and power to
monitoring of field outreach activities, there is now freely move funds across spending lines. Staff salaries
fragmentation between the health facilities and field have been raised above government-provided rates
activities. and there are discrepancies from district to district
The contracts also are not well specified in terms in terms of level of the hard allowances offered. So
of monitoring and supervision mechanisms and far there has been no public audit of PPHI accounts.
roles, nor do the district heath offices and provincial There is also lack of clarity and understanding of
departments of health have sufficient capacity to the contractual penalty system, and lack of use of
monitor contracts. A third-party role has not been arbitration. Typing in financial payments or bonuses
built in and was only conducted once through donor to targets could have been another mechanism
support.

39
to leverage the PPHI towards less-met targets, but • Improvement of Nutrition through Primary Health
these have also not been employed. Care.
“Turf” issues on control of budgets and authority Most of these have been initiated with donor
at lower levels, and lack of understanding and support to focus attention on a priority global area,
ownership of preventive programmes at the either through providing the major share of funding
higher provincial levels, have contributed to this (HIV, nutrition, maternal, newborn and child health)
fragmentation. District health officers have often or incentivizing government commitment with
complained of lack of financial and administrative a smaller matching share of funds (such as the
decision space to rectify district health service Expanded Programme on Immunization) or provision
delivery, and demanded similar sets of powers as of technical assistance (malaria, tuberculosis DOTS).
those given to the PPHI to allow fair comparison. In some cases it is the government that has set up
“Why are we being compared with the PPHI, give vertical programmes in areas of high political priority
me the same Class I powers, and see what I can do.” (Lady Health Worker Programme, Prime Minister’s
(district health officer) Programme for Prevention and Control of Hepatitis).
In summary, while the PPHI has been an extensive and Design, management, monitoring and funding
sustained reform measure, the lack of government had been through the federal government,
capacity to manage the outsourcing arrangements while provinces provide partial funding and
has led it to performing below its potential. implementation. Many of the vertical programmes
that started as vertical projects in the development
13.4 Integration of vertical programme budget were meant for horizontal integration into
structures the health care delivery system, but none have
been transitioned into the operational budgets of
Pakistan has a long history of implementing provincial governments. Vertical planning exerted by
vertical programmes and has the following vertical the Federal Ministry of Health, donor accountability,
programmes in place: and low ownership of preventive programmes in
• Expanded Programme on Immunization provincial government have combined to extend
• Prime Minister’s Programme for Prevention and the continuity of vertical programmes well beyond
Control of Hepatitis 30–40 years.
• Roll Back Malaria Following devolution, a desire for integration of
• National Programme for Family Planning and vertical programmes originated from declining
Primary Health Care federal support for these programmes and the need
• Lady Health Worker Programme for additional resources for implementation of the
• Enhanced HIV/AIDS Control Programme projects from the provincial government budget.
• National Tuberculosis Control Programme (sup- In those circumstances, the provincial health
ported by Strengthening National Tuberculosis departments weighed a number of options:
Control Programme by Ensuring Uninterrupted
Drug Supplies) • continuing with the vertical approach;
• National Programme for Prevention and Control of • partial integration of programmes having the
Avian and Pandemic Influenza same objectives at the PHC level;
• Maternal, Neonatal and Child Health Programme • complete integration of all vertical programmes
• National Programme for Prevention and Control of into the health systems.
Blindness

40
However, after much deliberation, it was agreed that The integration of vertical programmes, although
the desired results could be achieved using a phased well articulated at the planning stage, has been
approach for integration, gradually progressing to delayed in all provinces. This is primarily due to
complete integration over time. continued dual funding of the vertical programmes
by the federal government until 2016, and recent
With devolution, all provinces have developed
extension beyond 2016. The existence of an open
an essential health services package for primary
vertical budgetary line has thus hampered the
health care that is the basis for integrated provision
creation of a new budget line for vertical programme
of services through health facilities or community
staff and supplies. In Sindh and Balochistan, the
outreach. Khyber Pakhtunkhwa has moved to
move towards integration was also resisted by
structurally combine the vertical programmes into a
vertical programme managers. Many of the vertical
single essential or minimum service delivery package
programme managers enjoy political patronage,
having a single budget and one administrative and
and there has been insufficient strong and stable
monitoring structure. Development partners were
leadership in the ministry to overcome this barrier
requested to overcome the deficit on provincial
and move towards service integration.
financing from supporting the health sector in Khyber
Pakhtunkhwa. Punjab province has functionally “Behind every vertical programme director is a
integrated the vertical programmes into two major politician. How can change be brought in, in such
programmes – communicable disease control, a context?” (deputy director, vertical programme)
and maternal and child health and undernutrition
In summary, while devolution has provided
– while continuing the Expanded Programme of
space for integration of vertical programmes,
Immunization as a separate programme. Structural
the issues of continued dual funding and lack of
integration is proposed as the next step. Sindh and
sufficient leadership commitment has constrained
Balochistan have committed to integration in their
implementation.
sector strategies and have formulated the Health
Sector Plan, but integration is yet to move forward.

41
Annex 1. Key demographic, macroeconomic and health
indicators of Pakistan
Indicator Results Sources of information Remarks
Total population of country 184.35 million National Institute of Population Studies, 2016 (1)
Sex ratio: male/female 102 male/100 female PDHS 2012–13 (2)
Population growth rate 2% PDHS 2012–13
Population density (people/sq. km) 231 per sq. km PDHS 2012–13
Distribution of population (rural/urban) 61.4% rural, 38.6% urban National Institute of Population Studies, 2016
GDP per capita US$ 1316.6 World Bank, 2013 (3)
Income or wealth inequality Not available

(Gini coefficient)
Life expectancy at birth Male = 64.4 years PDHS 2012–13

Female = 66.5 years
Top 5 main causes of death (ICD-10 Top five causes of premature http://www.healthdata.org/pakistan
classification) mortality in Pakistan (2013)
1. Ischaemic heart disease
2. Lower respiratory infections
3. Cerebrovascular diseases
4. Neonatal encephalopathy
5. Diarrhoeal diseases
PDHS = Pakistan Demographic and Health Survey.

42
Annex 2. Demographic, macroeconomic and health profile
of Pakistan
Area Summary Source of information
Demographic profile Population: 184.35 million PDHS 2012–13 (2)

61.4% rural, 38.6% urban
Growth rate 2%
Sixth most populous country
Literacy rate: 43.4%
Macroeconomic profile GDP/capita: US$ 1316.6 World Bank, 2013 (3)

GDP growth: 4.7%
GNI/capita: US$ 4920
Ranking: Lower middle income
Health profile Total fertility rate: 3.2 PDHS 2012–13

Maternal mortality ratio: 274/100 000 PDHS 2006–07 (7)
Under-5 mortality: 89/1000
Neonatal mortality: 55/1000
Infant mortality: 74/1000

43
Annex 3. Basic information on Pakistan health system
Indicator Results Sources of information Remarks
Total health expenditure as proportion of GDP 2.8% Pakistan National Health Accounts 2011–12
(9); World Bank, 2013 (3)
Government health expenditure as proportion of GDP 1% World Bank, 2013
Public expenditure on health as proportion of total 36.8% World Bank, 2013

expenditure on health
Out-of-pocket payments as proportion of total 54.9% World Bank, 2013

expenditure on health
Voluntary health insurance as proportion of total 0.2% Health equity and financial protection
expenditure on health report, Pakistan: World Bank, 2012 (11)
Donor contribution as proportion of total expenditure 2% Health equity and financial protection
on health report, Pakistan: World Bank, 2012
Proportion of households experiencing catastrophic 5% Household Integrated Economic Survey,

health expenditure 2010–11
Number of physicians per 1000 population 0.8 WHO Eastern Mediterranean Region HRH 8/10 000
observatory, 2014
Number of nurses per 1000 population 0.6 WHO Eastern Mediterranean Region HRH 6/10 000
observatory, 2014
Proportion of population consulting the following for

general health consultation:
Private sector 71% Pakistan Social and Living Standards The later editions
Measurement Survey, 2008–09 (13) have not reported
consultation for general
Public sector 21% Pakistan Social and Living Standards health problems
Measurement Survey 2008–09
Homeopathy 1% Pakistan Social and Living Standards

Hakim 3% Pakistan Social and Living Standards


44
Annex 4. Focus group discussion participants
List 1
Sr. # Designation Organization City
1. Director Programmes MoNHSR&C Islamabad
2. R/A PSPU 120-B Muslim Town Lahore
3. DG Health DG Health Office Hyderabad
4. National Coordinator USAID Deliver Project Islamabad
5. Provincial Team Leader TRF+ Peshawar
6. DG Health DG Health Office Peshawar
7. Director Health DG Health Office Muzaffarabad
8. ADG MoNHSR&C Islamabad
9. Director Health Services Health Directorate FATA Peshawar
10. PA-HOSO (FATA) UNFPA Peshawar
11. Consultant HSRU, HP Peshawar
12. Director PHSA Islamabad
13. DDPH DG Health Office Peshawar
14. Coordinator HSRU Peshawar
15. DD (P&D) FATA Directorate Peshawar
16. Assistant Director EPI DG Health Office Peshawar
17. Manager P&A EVA-BHN H University Town Peshawar
18. Programme Manager 2-G Model Town Lahore
19. Project Director SHPI Peshawar
20. H&N Officer UNICEF Peshawar
21. Consultant TRF+ Office Peshawar
22. Chief HSRU Peshawar
23. CPO Health Department Peshawar
24. Additional Secretary Health Health Department Peshawar
25. Coordinator Health Secretariat Peshawar
26. PD-IMU Defense Officer Colony Peshawar
27. HSS WHO Country Officer Islamabad
28. GIZ Deputy Head F/8–4 Street 50 Islamabad
29. Health of Officer WHO KP/FATA University Town Peshawar
30. Consultant MoNHSR&C Islamabad
31. Consultant JSI Islamabad
32. Consultant HAS Islamabad

45
List 2
1. Director Programmes MoNHSR&C Islamabad
2. DG Health DG Health Office Hyderabad
3. Director Health DG Health Office Hyderabad
4. DG Health DG Health Office Quetta
5. Deputy Prov. Coordinator, MNCH Health Directorate Quetta
6. DG Health DG Health Office Peshawar
7. Director Health DG Health Office Muzaffarabad
8. DG Health Directorate of Health Gilgit-Baltistan
9. Coordinator HSRU Department of Health Peshawar
10. Director MCH-PIMS Islamabad
11. HO UNICEF UNICEF Office Lahore
12. Member P&D Department of P&D Lahore
13. Director Technical Healthcare Commission Lahore
14. Additional Secretary (Health) Directorate of Health Lahore
15. Director NCD & Mental Health 24 Cooper Road Lahore
16. ADGHS, IMRNCH 5 Montgomary Road Lahore
17. Provincial PM EPI Directorate of Health Lahore
18. Logistic & Procurement Officer 5 Montgomary Road Lahore
19. Programme Director EVABHN, DFID Lahore
20. Humanitarian Analyst UNFPA Lahore
21. Maternal Programme Specialist UNFPA Lahore
22. Training Coordinator, MNCH Health Department Karachi
23. R/A PSPU 120-B Muslim Town Lahore
24. PSPU PSPU Lahore
25. Director Health & Nutrition Save the Children Islamabad
26. HO UNICEF UNICEF Lahore
27. CEO AA Associates Islamabad
28. Director 3-A Temple Road Lahore
29. PHS Civilian Housing Society Lahore
30. Provincial Team Leader TRF-Plus Lahore
31. RMNCH Focal Person M/o NHSR&C Islamabad
32. Associate Prof. Children’s Hospital Lahore
33. Gynecologist Hameed Latif Hospital Lahore
34. PD QOC Standards Project Peshawar

46
35. Head office WHO 24 Cooper Road Lahore
36. TO-WHO WHO Country Office Lahore
37. NPO-HSS-WHO 24 Cooper Road Lahore
38. CPO UNFPA Lahore
39. YPO UNFPA Lahore
40. Hospital Administrator PSSHMC Hospital Lahore
43. Lead Resource Person AKU Karachi
47. RA(HW) PSPU New Muslim Town Lahore
48. Health Specialist Zaman Park Lahore
49. Consultant – Lahore

47
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This case study was developed by the Alliance for Health Policy and Systems Research, an international partnership hosted by the
World Health Organization, as part of the Primary Health Care Systems (PRIMASYS) initiative. PRIMASYS is funded by the Bill & Melinda
Gates Foundation, and aims to advance the science of primary health care in low- and middle-income countries in order to support
interventions worldwide. The PRIMASYS case studies cover key aspects of primary health care systems, including policy development
of care, governance and organization, and monitoring and evaluation of system performance. The Alliance has developed full and
abridged versions of the 20 PRIMASYS case studies. The abridged version provides an overview of the primary health care system,
tailored to a primary audience of policy-makers and global health stakeholders interested in understanding the key entry points to
strengthen primary health care systems. The comprehensive case study provides an in-depth assessment of the system for an audience
of researchers and stakeholders who wish to gain deeper insight into the determinants and performance of primary health care systems
in selected low- and middle-income countries.
World Health Organization

Avenue Appia 20
CH-1211 Genève 27
Switzerland
alliancehpsr@who.int
http://www.who.int/alliance-hpsr

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PRIMARY HEALTH CARE SYSTEMS

Shehla Zaidi, Nasir Idrees, Atif Riaz

Aga Khan University, Department of Community Health Services

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

COMPREHENSIVE CASE STUDY FROM PAKISTAN

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

COMPREHENSIVE CASE STUDY FROM PAKISTAN

COMPREHENSIVE CASE STUDY FROM PAKISTAN

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

COMPREHENSIVE CASE STUDY FROM PAKISTAN

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Total fertility rate 3.8 births per woman PDHS 2012–13

Underweight: children 31.5% NNS 2011 (6)

Stunting: children 43.7% NNS 2011

Wasting: children 15.1% NNS 2011

Anaemia: children 62.0% NNS 2011

Anaemia: pregnant 51.0% NNS 2011

COMPREHENSIVE CASE STUDY FROM PAKISTAN

Source: World Health Organization (8).

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

COMPREHENSIVE CASE STUDY FROM PAKISTAN

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

COMPREHENSIVE CASE STUDY FROM PAKISTAN

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Figure 2. Health expenditures by financing agents

District Govt. 7.6% Military Health 3%

Source: National Health Accounts 2011–12 (9).

COMPREHENSIVE CASE STUDY FROM PAKISTAN

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

COMPREHENSIVE CASE STUDY FROM PAKISTAN

Medicines and supplies Medicines and supplies

Operating expenditure Operating expenditure

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Table 3. Health spending and utilization

Private sector 71%

Public sector 21%

COMPREHENSIVE CASE STUDY FROM PAKISTAN

Table 4. Health facilities by type

Number of health facilities by type

Azad Jammu and Kashmir 6 12 34 208 260

Balochistan 27 10 82 549 668

Federally Administered Tribal Areas 4 14 9 174 201

Khyber Pakhtunkhwa 21 77 90 822 1010

Punjab 34 84 291 2454 2863

Sindh 11 56 130 774 970

Total 108 280 638 4996 6021

Source: Health facility assessment (15).

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

Parastatal institutions also make an important

providing free-of-cost services to the armed forces, Traditional care providers 19

departments of either self-owned hospitals or the Traditional care provider –

Traditional health care providers 3

COMPREHENSIVE CASE STUDY FROM PAKISTAN

Figure 5. Comparison of private health sector

Overall Private Sector Utilization

Source: Hafeez A (17).

PRIMARY HEALTH CARE SYSTEMS (PRIMASYS)

family physicians, though these are mostly in private Nurses 82 119

Figure 6. Human resources for health in Pakistan: ratio of workforce to population

Per 1000 population

family physicians, though these are mostly in private Nurses 82 119