Khyber Pakhtunkhwa Health Sector Review

Hospital Care

• Publisher: Asian Development Bank
• Year: 2019
• ISBN:
  9789292617653
• Topic: Política y relaciones internacionales
• Subtopic: Política social

This publication presents a detailed review and assessment of the governance, infrastructure, and financing aspects of hospital care in Pakistan's Khyber Pakhtunkhwa Province. Fast demographic growth, poor access to and utilization of health services, an underfunded public health system, and fragmented reform initiatives are among the key challenges in the province. The Government of Khyber Pakhtunkhwa commissioned the Asian Development Bank to conduct the review to aid the creation of a comprehensive strategy to guide investments and projects in the health sector.

CHAPTER 1
Introduction

I. Overview

In 2017, the Department of Health (DOH) of the Government of Khyber Pakhtunkhwa requested the Asian Development Bank (ADB) to commission a health sector review focusing on health governance, health infrastructure, and the health financing aspects of hospital care. The key objectives of the review were to identify bottlenecks and opportunities within the three focus areas and to lay the foundation for the development of a sector-wide Khyber Pakhtunkhwa health plan. The review was based on a critical appraisal of current documents and data available in the DOH and allied offices, a quantitative survey of 30 secondary care hospitals, and two missions to Khyber Pakhtunkhwa in November 2017 and February 2018. This section broadly outlines the socioeconomic profile of the province and the health sector context, as well as the scope, purpose, and methodology of the review.

II. Provincial Socioeconomic and Health Sector Context

Socioeconomic Status

Khyber Pakhtunkhwa is in the northwestern region of Pakistan and is one of the country’s four administrative provinces. Although Khyber Pakhtunkhwa is the smallest province geographically with 7 divisions and 26 districts,¹ its total population has increased from 17.7 million in 1998 to 30.5 million in 2017 according to recent census estimates, and the population growth rate (2.89%) exceeds the national rate (2.40%). The vast majority of the population reside in rural areas (81%), with a few densely populated urban centers including Peshawar, which has a population of 2.1 million.² Over 3 million Afghan refugees are estimated to be residing in the province.

Following several years of conflict and political instability, the province currently faces considerable challenges that have restricted economic and social progress. The economic activity in the province has been negatively impacted due to an influx of refugees, violence, and a prolonged state of insecurity. With an underdeveloped manufacturing sector, the main sources of economic activity come from the forestry and agriculture sectors. The province generates 8% of Pakistan’s gross domestic product (GDP) with a per capita value of $800, half the national average per capita value.³ The overall literacy rate is 54.1%, the lowest among the provinces; the literacy rate for females stands at an abysmal 36.8%.⁴

All urban households and 91.4% of rural households have access to electricity. More than 92% of the population (70% urban and 87% rural) own the house they reside in, while 92.7% of the population own a mobile phone. Solid fuel consumption for cooking is at a staggering 68%, which implies a high level of indoor pollution. However, 97% of these households do not cook in the room they sleep in. This measure is important for gauging physical proximity to indoor pollutants. It is also pertinent to note that of the 68% that use solid fuel for cooking, most are in rural areas. A majority of urban households (68%) use natural gas for cooking.⁵

Improved water and sanitation are accessible to 96.5% of urban and 86.5% of rural areas.⁶ However, only 24.5% of the urban and 21.4% of the rural population use piped water. About 96% of urban and 81% of rural households have access to improved sanitation.⁷ Overall, more than 77% of the population have access to both improved drinking water and sanitation; of this, 93% belong to urban and 72% to rural households (footnote 5).

Health Status

Pakistan has traditionally had poor health outcomes relative to other countries in South Asia and East Asia. In Khyber Pakhtunkhwa, many weaknesses and challenges have been identified in the current Health Sector Strategy (HSS),⁸ including poor access to and utilization of health services, low quality and effectiveness of care, limited managerial capacity and weak accountability at all levels, systematic underfunding of the public health system, inefficient and inequitable resource allocation, low financial protection, and fragmented and discontinued reform initiatives.

The health outcomes of the province need substantial improvement and present an uphill task in achieving the Sustainable Development Goals. As per the Khyber Pakhtunkhwa Health Survey 2017, 67.5% of births were delivered in health facilities, but only 26.8% stayed for at least 12 hours for postnatal care (footnote 5). The neonatal mortality rate is 41 per 1,000 live births, the infant mortality rate is 58 per 1,000 live births, and the maternal mortality ratio is 206 per 100,000 live births.⁹ Of children aged 12–23 months, 55.5% are reported to be fully immunized (based on records and mother’s recall) (footnote 5). Approximately 17.3% of children aged 0–23 months have not received any vaccination at all. Over 40% of women have nutritional health problems (underweight, overweight or obese, anemic, iodine or zinc deficient), while 24% of children below 5 years of age are underweight, 48% are stunted, and 17% are wasted.¹⁰

Key Health Reforms

Several reforms have taken place in the health sector within the past decade. In 2010, the 18th Constitutional Amendment of Pakistan devolved health administration to the provinces, granting legislative as well executive authorities in the health sector, previously within the purview of the federal government, to the provinces.¹¹ At the time of devolution, Khyber Pakhtunkhwa already had the HSS 2010–2017 in place, but the process triggered a series of reforms aimed at addressing the unique challenges faced by the province with regard to strengthening the health system at large.

A key aspect of the devolution process has been electing local governments. The local government in Khyber Pakhtunkhwa has three tiers: district, tehsil,¹² and village. The mother and child health centers, rural health centers (RHCs), basic health units (BHUs), social welfare, population welfare, public health engineering, and public health hospitals have been devolved to the districts. Tertiary and teaching hospitals are devolved to the province. The devolution of financial power that allows the local governments to reallocate their assigned budget to areas of their choosing is among the most critical devolutions of powers to the local government and allows the local governments to deal with endemic and emergent issues within their jurisdiction more flexibly and effectively. The provincial government has been on an ambitious mission to reform the health landscape through various legal and programmatic initiatives.

Health policy in Khyber Pakhtunkhwa is informed mostly by the Khyber Pakhtunkhwa HSS 2010–2017 and National Health Vision 2016–2025.¹³ The provincial HSS 2010–2017 was extended until June 2018. Efforts are underway to update the strategy and align operational planning, midterm budgetary framework, and district-level health plans with this strategy.¹⁴ Furthermore, since 2011, more than 23 ordinances/acts and amendments about health care have been passed in Khyber Pakhtunkhwa. Some of these are novel and introduce new dimensions in terms of quality, access, and service delivery, while others, mostly amendments, seek to update the existing laws. The most critical of these laws include (i) Khyber Pakhtunkhwa Health Care Commission (HCC) Act, 2015, which aims to regulate the health care in the province through sound technical knowledge; (ii) the Khyber Pakhtunkhwa Public Health (Surveillance and Response) Ordinance, 2017, the goal of which is to implement measures that help prevent and control diseases in the province; and (iii) the Khyber Pakhtunkhwa Medical Teaching Institutions Reforms Act, 2015, which seeks to provide autonomy to the government-owned medical teaching institutions and their affiliated teaching hospitals to improve their performance in and responsiveness to the provision of quality health care services (see Chapter 2 for a detailed description of these key health sector policies and reforms).

In addition, the Government of Khyber Pakhtunkhwa launched a provincial social health protection initiative (SHPI) called the Sehat Sahulat Program in December 2015. The current reach of the program stands at 51% of the Khyber Pakhtunkhwa population and is being scaled up to 69%. The present benefit package provides 100% coverage for maternity care and cancer in the outpatient department (OPD), as well as all illnesses requiring hospitalization in secondary care hospitals and limited tertiary cover.¹⁵ The Khyber Pakhtunkhwa Health Roadmap, which was launched in 2016, is an initiative that seeks to carry out targeted interventions in critical domains within the health sector. As new initiatives are being launched, such as management and operation of health facilities through public–private partnerships (PPPs), a contract management unit has been established to ensure efficient allocation of resources and effective collaboration between public and private entities. A health sector reforms unit was founded in 2014 to ensure that planned reforms are based on sound technical knowledge and to coordinate those reforms that have been undertaken. The health sector reforms unit is responsible for coming up with locally relevant solutions to the challenges faced by the province.

Furthermore, human resources for health (HRH) have been expanded through better incentives for medical staff. Overall, 3,000 new medical officers and other staff have been hired. Multiple health facilities at all levels are being renovated. The district health information system (DHIS) has been strengthened, and its quarterly reports are more regularly utilized to inform evidence-based decision-making as the reports provide disease patterns at health facilities and service utilization trends, among other information.

III. Purpose and Scope

ADB has been providing technical and financial support to the health sector in Pakistan for the last 20 years. ADB’s Operational Plan for Health, 2015–2020 identifies three key areas of investment for supporting the developing member countries to achieve universal health coverage (UHC). Upon the request of the Department of Health of Khyber Pakhtunkhwa, ADB commissioned this health sector review with a focus on (i) health governance, (ii) health infrastructure, and (iii) health financing.

The key objectives of the review were to identify bottlenecks and opportunities within the focus areas and to lay a foundation for the development of a sector-wide health plan. Although the review takes a broader view of the health sector, the key focus remains hospital care. For health governance, there is an emphasis on hospital autonomy and contracting. Within health infrastructure, the review looks at the status of physical and human resources, projections on demand for inpatient services, and quality of hospital care. Finally, the health financing section presents the current state and challenges according to specific health financing functions, including revenue collection, pooling, and purchasing, focusing on three critical elements of universal coverage, such as breadth, scope, and depth. Closely intertwined with health financing is public financial management (PFM), which plays a crucial role in ensuring that public funds provide sustainable financing. The PFM challenges are also presented for each of the health financing functions using the framework of the World Health Organization (WHO) in aligning PFM and health financing.¹⁶ Each section ends with some recommendations moving forward.

IV. Methodology

The review began with a comprehensive desk review of current documents and data available from the DOH and allied offices. The review team, comprising ADB staff and international and national experts in governance, health facility planning, health financing, quality improvement, and behavior change communication, conducted a quantitative survey in secondary care hospitals with the support of Khyber Medical University. The facility survey covered 37 facilities including 6 teaching and specialized hospitals (1 private), 8 district headquarters (DHQ) hospitals (1 private) and 12 tehsil headquarters (THQ) hospitals, 3 other hospitals, 4 RHCs, and 4 other outpatient facilities. The survey aimed to shed additional light on the key governance and accountability issues identified in the HSS 2010–2017. During November 2017–February 2018, the ADB review team conducted two missions that involved detailed discussions with stakeholders—including more than 100 individuals from the DOH, allied offices, and government hospitals—and six on-site visits to secondary care hospitals.

After review and analysis of reports, statistics, and other documents, a questionnaire and a checklist were developed to guide the review visits at six selected secondary level hospitals.¹⁷ The DOH purposively selected these 6 out of 97 secondary level hospitals in Khyber Pakhtunkhwa to represent a range of contexts in the province. Further, a team from the Khyber Medical University’s faculty conducted a survey on both service performance in 7 out of 19 DHQ hospitals and the key referral structures at the district (secondary care) level.

CHAPTER 2
Health Governance

I. Overview

In sector and facility governance, reforms within Khyber Pakhtunkhwa have focused mostly on (i) providing managerial autonomy to tertiary hospitals or medical teaching institutions (MTIs) and, to a lesser extent, to other public health facilities; (ii) contracting out the provision of certain primary and secondary health services to private providers; and (iii) strengthening the health information systems such as the DHIS and health management information system (HMIS) for monitoring and evaluation (M&E) of health facilities.

While these reforms represent substantial advances toward strengthening the health system and improving its performance, fundamental weaknesses remain that can prevent or derail the implementation of these reforms or dilute their impact. This section looks at the health sector and health facilities governance and facility-level autonomy in Khyber Pakhtunkhwa as critical building blocks of the provincial health system.

II. Achievements

Health sector regulations in Khyber Pakhtunkhwa are quite comprehensive. Since 2011, more than 23 ordinances/acts and amendments about health care have been passed in Khyber Pakhtunkhwa. Some of these are novel and introduce new dimensions in terms of quality, access, and service delivery, while others, mostly amendments, seek to update the existing laws that are not in line with modern medical, scientific, or social standards. The most critical of these laws include the following:

• Khyber Pakhtunkhwa Health Care Commission Act, 2015. It aims to regulate the health care in the province through sound technical knowledge, resulting in the establishment of the HCC—a statutory body constituted in 2015 as a transformation from the previous Health Regulatory Authority to supervise both public and private health care providers—with multiple roles including (i) developing registration and licensing standards, (ii) establishing and enforcing minimum quality and safety standards, (iii) enhancing capacity of registered and licensed individuals, and (iv) imposing fees and fines. The HCC carries out these functions through multiple committees.

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