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The Gateway Paper – towards a health systems reform

Published in The News International on March 19, 2006:

Released on January 9, 2006, the first publication of Pakistan’s Health Policy Forum (PHPF), the Gateway Paper entitled “Health Systems in Pakistan – a Way Forward” is set within a broad context. A context relevant to health on the one hand and one that cross cuts with broader social sector issues, inter-sectoral processes and mainstream governance and sustainable development challenges, on the other.

Pakistan’s Health Policy Forum has recently been created as the country’s first health sector Think Tank with the overarching mission of providing an independent voice for the promotion of the health and well-being of the country’s population. Its specific objectives are to review and analyze health ‘policies’ and ‘systems’, assess gaps and offer solutions to address impediments and to catalyze change through technical and policy support. The Forum/Think Tank is envisaged to play an important role in promoting accountability of decisions by educating the civil society in the dynamics of health care delivery, policy and financing; mobilizing their participation in the health policy process and mainstreaming the voice of the civil society in decision making – an attribute critical to strengthening the ‘societal’ political culture. An initiative of the NGO Heartfile, Pakistan’s Health Policy Forum is the largest grouping of stakeholder organizations and individuals in the health sector. (http://heartfile.org/hpf.htm).

In a true sense, the Gateway Paper is a gateway or opening of new effort to address the pressing health needs of the country. The intent is to articulate the raison d’être for health reforms within the country, propose a direction for reforms and emphasize the need for an evidence-based approach to reforms. The Paper has also been structured to assist PHPF with the setting of its priorities and to guide its analytical and technically supportive functions needed to support health systems reforms in the country.

Making a strong case for ‘systems reforms’, the Paper provides linkages with Pakistan’s health systems and its policy cycle providing a strategic view on how they can work better together. The Paper reviews issues and proposes solutions for the basic functions of health systems – stewardship, financing, service provision and inputs. It also discusses three distinct interface areas critical to performing these functions; these are the federal-provincial interface, decentralization and the public-private interface. In addition, the Gateway Paper also focuses on several overarching health paradigms such as health promotion, legislation, research and the inter-sectoral scope of health as singular areas, with the understanding that each of these is cross-cutting in its scope. In its Finale, the Gateway Paper synthesizes recommendations from each health systems domain discussed in the paper and presents a viewpoint on the proposed directions for evidence-based health systems reforms in Pakistan. The proposed reforms point in the direction of four broad areas namely, reforms within the health sector, overarching reforms, reconfiguration of health within an inter-sectoral scope and generating evidence for reforms.

Within the health sector, the proposed reforms focus on strengthening the role of the State as the principal steward of the health system; setting of priorities for the use of public funds and definition of priority services to be provided universally and developing alternative service delivery and financing options at the basic healthcare and hospital levels. Within the context of the latter, this includes community co-management and contracting out arrangements for basic health care, maximizing efficiency in the same system or transferring management to lower levels of government – an option complementary to the administrative arrangements within decentralization – whereas with reference to hospitals this involves granting autonomy at a management level and the introduction of cost-sharing at the level of financing. The paper also makes a strong case for building the capacity of and effectively deploying human resource, establishing a conducive and rewarding working environment and initiating measures to redress imbalances with regard to the existing staff.

At an overarching level, three proposed directions of reform have been articulated; the first involves establishing a legal, policy and operational framework for public-private partnerships in order to foster arrangements that bring together organizations with the mandate to offer public good on the one hand, and those that could facilitate this goal through the provision of resources, technical expertise or outreach, on the other. The second includes building conscious safeguards in order to offset the risk of creating access and affordability issues for the poor in the new service delivery arrangements which mainstream the role of the private sector. This includes the establishment of social health insurance as part of a comprehensive social protection strategy that scopes beyond the formally employed sector, providing a widely inclusive safety net for the poor and the strengthening of waiver and exemption systems in order to provide subsidies to treat poor patients. And the third focuses on institutionalizing civil service reforms centered on good governance, accountability, crackdown on corruption, factoring in of performance-based incentives, mainstreaming managerial audit and building safeguards against political and external interference.

The proposed reforms within an inter-sectoral scope entail developing alternative policy approaches to health within its inter-sectoral scope with careful attention to the social determinants of health and several contemporary considerations that influence health status – in other words, broadening the ‘healthcare system’ to a ‘health system’. Most of the available information about Pakistan health systems refers to provision of and investment in health services curative more than preventive and palliative – directed at individuals and populations. This constitutes the healthcare system; however a health system is much broader; this underscores the need for health to be viewed in its inter-sectoral scope. It is well established that many factors which determine health status range much broader than those which are within the realm of the health sector. Health cannot be extricated from the political, economic, social and human development contexts. It is well established that liberalization of international trade, global infectious disease pandemics, natural disasters and humanitarian crises can be detrimental to health outcomes as can be changes in international cooperation and geopolitical situations which can have implications for the manner in which health is resourced in a country such as Pakistan.  The proposed reforms in ‘health’s intersectoral scope’ necessitate redefining targets within the health sector in order to garner support from across various sectors and setting these targets within an explicit policy framework in order to foster inter-sectoral action. In addition this also warrants the creation of intersectoral agencies that concentrate on prevention and health promotion at multiple levels – legislative, ministerial and others as necessary; development of dedicated provincial agencies that implement such programmes and overarching policy and legislation for health promotion.

The fourth area of emphasis is on generating evidence for reforms. Health reforms must be firmly grounded in evidence, which in turn, should be utilized for appropriate modifications as the reforms get on their way to being implemented – an approach, which allows action accompanied by rigorous evaluation and up-gradation of programmes and policies. The individual components of the health reforms being proposed also mandate robust evaluation; this can allow the evaluation of competing concepts and can, therefore, guide the up-scaling of appropriate initiatives for broader systems-wide adoption. This is critical to the development of well-structured and sustainable service delivery and financing mechanisms. The Gateway Paper outlines a list of priority areas where health policy, systems and operational research should focus in order to yield evidence critical to the success of the proposed reforms. The Paper also outlines policy frameworks, institutional mechanisms and norms and standards required to support the reforms it proposes thereby providing a clear linkage of conceptual thinking to practice.

The proposed reforms outline the need to strengthen systems and institutions, build capacity and foster a greater commitment to basing decisions and actions on evidence. However, health cannot be extricated from the political, economic, social and human development contexts and reforms within the healthcare system and the health system at large cannot be separated from several overarching processes. Poor regulation, gaps at the governance and management levels and lack of appropriate incentives contribute to lack of efficiency, staff absenteeism and abuse; these are compounded by lack of accountability within the system and lapses in social justice, which in turn cannot be extricated from overall macroeconomic and social development. Sustainable progress at the health systems and healthcare systems levels, therefore, depends to a large extent, on the manner in which progress is made in all these areas in addition to human development, the overall rate of economic growth and improvements at a governance level. With the current trend of economic growth, it is important to pay close attention to these overarching processes as these are critical to impacting social sector indicators within the country. Health reforms can undoubtedly be an entry point for these structural changes

The author is the founder and president of the NGO Heartfile and Pakistan’s Health Policy Think Tank/Forum and the author of the Gateway Paper. E mail: sania@heartfile.org

Avian Flu – the short and long term contexts

Published in The News International on March 05, 2006:

Given that diseases such as the Plague, SARS, HIV/AIDs and Avian Flu do not respect national boundaries, the news of Avian Flu in our immediate neighborhood, left a slim choice between treading the prevent-prepare-control options a week ago. However its detection on an NWFP farm yesterday, made choices much clearer. Ever since Avian Influenza (H7N3) hit Pakistan in 2003-04 and was subsequently curbed at source in the agriculture and health sector through implementation of animal and human health surveillance, disease control and mitigation measures, some level of gearing up for another outbreak had been witnessed. Evidenced by news and other forms of reporting, efforts included the establishment of surveillance laboratories equipped to diagnose bird flu; enhanced allocations for strengthening surveillance and emergency preparedness and clinical, serological, and virological surveillance in migratory birds from different parts of the country. It is hoped that these investments will pay off given the recent emergence of the virus in NWFP.

However, the situation specific to Avian Flu and the earlier experience relating to the health situation consequent to the October 8 earthquake raise several policy questions for medium- and long-term planning. These relate to striking a balance between the short and the long-term measures; the capacity within the system to respond to a health crisis; the level of preparedness of the health systems to deliver emergency services; and most importantly, the extent to which a credible cost-effective and equity-focused analysis supports investments in these within a long term context. Three overarching issues of concern have been flagged here particularly with regard to medium and long-term planning.

Strengthening health systems:  the threat of the Avian Flu looming has once again highlighted the need for strengthening what is generally the ‘invisible’ in the social sector – institutional systems and capacity. Decades of focus on programme-based service delivery and an over-emphasis on infrastructure development have led to neglect at the health systems level. On-ground analyses indicate that the success of any health programme depends on the robustness of the health systems; indeed one of the markers of such systems’ strength is the degree of preparedness and responsiveness to public health emergencies.  Indeed many of the measures necessary to address the current challenge—particularly at the health sector level—are embedded in systems-level solutions.  For instance, bulk purchase of anti-virals for people and vaccines for birds links in with procurement mechanisms in the public sector; their inventory management and distribution from central base/s to the grass roots level is dependent on a friction-less Federal-Provincial-District service delivery interface; the missed opportunities to deliver them through private sector health care providers ties in the need to leverage on the private sector to deliver state-mandated-health-related public goods and the ultimate provision of these vaccines and medicines at the grass roots levels forms an integral part of the service delivery potential of basic health infrastructure.  Furthermore, designating hospitals for the treatment of the infected and equipping them to treat and care for affected individuals links in with issues of efficiency and sustainability.  Prompt dissemination of standard treatment guidelines and training health workers in such diseases ties-in the role of continuing medical education programmes – currently nonexistent in the country.  Systems-level solutions also need to be placed in the right structural, fiscal, and regulatory parameters; for example, another Avian Flu imperative which involves identification of laboratories for testing human and animal blood samples highlights the need for establishing a legal system that mandates the notification of diseases and regulates laboratory practices.

Strengthening systems must also proceed in tandem and with careful attention to the state asserting a stronger normative role. In the present situation guidelines for prevention and control of human cases of Avian flu influenza disease have been established by the National Institute of Health in collaboration with international partners; these must be widely disseminated.  In addition, the State’s normative role in this situation needs to be further augmented within the broader context of the prevention- and control-focused methodologies and instruments.

Health Disaster Preparedness: secondly crises – natural or manmade – are marked by increased level of death and suffering and put health systems through complex and unique emergencies.  Health policies should, therefore, incorporate disaster planning within their realm with a focus on preparedness, response, and recovery fostering collective responsibility to act effectively and enabling the development of new mechanisms and systems for health governance in the wake of these considerations.  A National Health Disaster Preparedness Plan developed within an overarching disaster management framework is therefore, a strategic imperative; this must pay careful attention to mapping human resources and infrastructure, inventorising demands and developing contingency plans.

Health’s inter-sectoral scope: thirdly, it is well established that much of the scope of the public health work is conventionally placed outside the medical care service and that factors which determine health status range much broader than those which are within the realm of the health sector. Environmental changes such as global warming and changing ecosystems may have implications for spread of disease and its control; mass damage by biological weaponry is a possible threat to civil infrastructure with serious public health implications; natural disasters raise public health issues of great significance; humanitarian crises as a result of conflict and acts of terrorism are known to impact health status of those affected and global pandemics such as the recent SARS and Avian flu epidemics have cut health across the global economy and allied sectors, taking health concerns to a completely different level.

It is therefore imperative that alternative policy approaches be developed for health within an inter-sectoral scope. This necessitates a redefinition of objectives and targets within the health sector in order to garner support from across the sectors. However, these need to be set within a more explicit policy framework in order to foster inter-sectoral action. Relevant ministries and organizations need to own this approach and participate in a manner, which is mutually supportive of common goals. Support for this should come from the highest ministerial level in each instance and should also reflect the support of the Cabinet. Within this context, Avian flu is a case in point which ties the role of many government departments and the private sector.

With the threat looming, it is understandable that policy objectives must focus on short term planning; as part of such efforts mobilizing the public as a key partner in beating the disease, measures to compensate poultry owners and encouraging them not to conceal a bird flu outbreak by providing specific incentives, and formulating a short-term incident management program with clear designation of roles and responsibilities and a command and control system to effectively minimize loss in the event of an outbreak are therefore justified.  However, daunting as they may seem – these should not prevent institutionally sustainable action set within the long term perspective given that this would be critical to strengthening the systems’ ability to cope with such disastrous events in future.

The author is the founder and President of Heartfile and Pakistan’s Health Policy Forum. E mail sania@heartfile.org