H ealth S ector R eforms

1. HealthSectorReforms To Support RBM Implementation in Health Sector, Pakistan

2. Outline of Presentation • Defining health sector reforms, current interest and significance for developing countries • Scope, objectives and guiding principles for HSR • Actions needed to achieve “Result-based Management” through HSR • Proposed HSR Agenda for Pakistan • Broad Strategies to implement HSR Agenda in Pakistan • Conclusion

3. What is HSR ? Reform means positive change, HSR implies “sustained, purposeful and fundamental change”–to address the needs of the communities for provision of equitable healthcare services.(Berman, 1995). Fundamental Change Sustained Purposeful

4. Definition of Health Sector Reform • Health sector reform is “a fundamental rather than an incremental change, which is sustained rather than one-off, [and] purposive in nature” (Cassels:1997). • According to Cassels, health sector reform includes: • Improving the performance of civil services • Decentralizations of power and resources • Improving functions of national health ministries • Broadening health financing mechanisms • Introducing managed competition • Privatization

5. Current interest in HSR D E E C V O E N L O P M I I N E G S Inequitable Healthcare access Lack of Social Protection Population Growth Increasing Poverty Unemployment Volatile Socio-economic Brittle Governance

6. Overall HSR Objectives The overall objectives is: “to improve the health status of the population through provision of equitable, affordable and efficient quality health care services” Equity Good Governance Community Participation Sustainability Quality Assurance Efficiency

7. HSR for fairness:Connecting equity, accountability, and efficiency • Equity in services, and financing:requirement of social justice, and fairness • Accountability:requirement of justice because we have fundamental interest in fairgovernance, also instrumentally important to efficient, equitable delivery of services • Efficiency:efficient systems can get better value for money in meeting needs under resource limits; requires integrated focus on equity, so goals work together.

8. Scope and Guiding Principles for HSR in support of RBM • Bridging the gap between health policy and implementation • Evidence-based decision-making through decentralized health management • Provision of cost-effective and affordable quality healthcare services • Improving equitable access and coverage • Addressing local needs and solutions through community participation • Achieving improved health status

9. Health Sector Reforms in Pakistan • Pakistan is an important strategically located country in South East Asia, ranking 6th in terms of population. • Total Population—150 million (double in 2040 with current growth rate of 1.9%), • 35% of population live below poverty-line • Total Health Expenditures—US$ 16 per capita • Nine times increase in UNEMPLOYMENT since 1971 • Only 20% population utilizes public health facilities and 80% goes to private for profit • The financial allocation for health is 0.88% of GDP

10. Vision for HEALTH INDICATORS in Pakistan

11. Issues and Problems of Health Sector in Pakistan

12. Issues and Problems of Health Sector in Pakistan

13. HSR Agenda for Pakistan • Strengthening of devolved District health System (DHS) to address inadequacies in healthcare services • Removal of professional and managerial deficiencies • Correction of urban biased healthcare services • Promotion of greater equity in health sector • Improving governance in MoH, DHS, and healthcare provider organizations • Introduction of operational policies for management development • Strengthening of M & E for performance improvement/appraisal • Regulatory and legal framework for performance management & accountability • Alternative funding strategies for health • Cost-recovery and cost-sharing mechanisms • Strengthen the government’s approaches to Private healthcare sector regulation • Regulation and accreditation of private health sector • Standardization

14. Proposed HSR Agenda—Strengthening of DHS • Strategy One—ESTABLISH through Devolution • District Health Management Team • Capacity building of the district staff to handle the decentralized health system • Explicit Clarification of roles and responsibilities of different components of decentralized District Health System (DHS) • District Health Planning System • Provide support to develop District Health Plan (DHP) • Develop necessary tools and instruments for planning functions by the district Devolution: • The most popular reform defined as “transfer of resources, functions and authority from the center to the geographically defined periphery”. • The devolution is said to support local bureaucracies to better adapt to local needs and demands. • Thus improving efficiency, quality and utilization of services

15. Proposed HSR Agenda—Strengthening of DHS • Strategy Two—ENSURE • Strengthening the capacity of District Health Department • Managing Change through innovation, learning experiences, research & development • Re-designation and creation of new cadres appropriate for decentralized district health system • Regulatory and legislatory support • Linkages among all DHSs through explicit mechanism • For sharing information, knowledge and skills for public health practices

16. Proposed HSR Agenda—Strengthening of DHS • Strategy Three—PROMOTE • Introduction of ‘Purchase-Provider Split’ between DHD and District Health Institutions • DOH, DHQ and THQ Hospitals for delivery of cost-effective healthcare services • Options for public-private partnerships in the district • Explore new avenues for PPPs e.g. NGO run Hospitals • Quality Assurance Systems (QAS) at all tiers of healthcare system

17. Proposed HSR Agenda—Strengthening of DHS • Strategy Four—DEFINE • Strengthened referral system within the district • Develop referral guidelines • Health services packages for all tiers of delivery system • Developing necessary manuals and guidelines for successful implementation

18. Steering Role of Provincial Health Department (PHD) Capacity Building Coordinating Healthcare Delivery Monitoring Regulating PHD Policy into Planning Guidelines Technical Support National Programs

19. Proposed HSR Agenda—Good Governance • Develop operational policies for different management components • HRM & D • Review of job descriptions & Cadres • Review of remuneration packages • Performance-linked contracts • Trainings & training needs assessment • Career mobility & development • Procurement & supplies • Review of current procedures & practices • Criteria, standardization, selection and specification • Regulatory mechanisms

20. Proposed HSR Agenda— Good Governance • Cont:Develop operational policies • Financial management • Financial Manuals for devolved DHS • Review of procedures & practices • Accountability • Assets & Logistics • Manuals and guidelines for devolved DHS • Review of procedures & practices • Health Institution Database (HID) • Service delivery • Review of existing models of service-delivery • Institutional guidelines & manuals

21. HSR Agenda—Good Governance • Performance • DHS performance • Establish benchmarks for every DHD—District Profile • Evaluating against the preset targets through uniform criteria & standard • Institutional performance • Institutional guidelines & manuals • Evaluating against the preset targets through uniform criteria & standard • Individual performance • Review of existing systems—ACRs • Linking performance with career mobility & development

22. HSR Agenda—Alternative Funding Strategies for Health • Strategy One—COST-SHARING • Strengthen existing finance generation schemes in the district • Extension & Expansion of “User-Charges” • Cost-sharing for drugs • Public-Private Partnerships • Prepayment Schemes • Hotel Services • Provide necessary support to implement and testing the interventions

23. Proposed HSR Agenda—Alternative Funding Strategies for Health • Strategy Two-COST-RECOVERY • Grant fiscal autonomy to Tertiary/DHQ Hospitals through phased approach with gradual reduction of public subsidy • Expand hospital financing by linking with “HI Schemes”, “Purchaser-Provider Split” and other Cost-recovery mechanisms • Strengthen DHQ Hospitals to become END-REFERRAL Centers • Provide necessary support to implement and testing the interventions

24. HSR Agenda—Alternative Funding Strategies for Health • Strategy Three—COST-POOLING • Health insurance Schemes • Introduction of Community-based Health Insurance Schemes (CBHI) • Introduction of Health Insurance Schemes for Public Sector Employees • Social Health Insurance • Provide necessary support to implement and testing the interventions

25. Proposed HSR Agenda—Regulation • Provide regulatory and legislative support for public and private health sector regulation • Identify and address the gaps in public and private health systems regulation • Develop consensus and implement legislation

26. Proposed HSR Agenda—Regulation • Strengthen the capacity of MoH, DHD and DHS to enforce the legal mandates in public health practices • Develop new tools and instruments for Food, Drugs, Standardization, Licensing and quality assurance regulation • Strengthen the laboratories and equipment used for regulation and QA (DTL, Chemical Examiner etc.)

27. Conclusions • HSR should be sustained and evolve through continuous process • Institutional development and capacity building is key to success • More resources should be made available for reforms • Reform strategies should be regularly reviewed and adjusted according to country context.

28. THANK YOU