National Health Policy 2009 Pakistan

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ZERO DRAFT – 19 Feb 2009
National Health Policy 2009
Stepping Towards Better Health
March 2009
Ministry of Health
Government of Pakistan
orward !y the Minister of Health
ii
"!!reviations
AI Avian Influenza
AIDS Acquired Immune Deficiency Syndrome
BHU Basic Health Unit
BISP Benazir Income Support Programme
BoD Burden of Disease
CCB Community Citizen Board
C! Community id"ife
CP# Contraceptive Prevalence #ate
DA$%s Disa&ility Ad'usted $ife %ears
DHDC District Health Development Center
DHIS District Health Information System
DH( District Head (uarter
D)H Department of Health
D)*s Directly )&served *reatment + short course
,m)-C ,mergency )&stetric and -eonatal Care
,PI ,.panded Programme on Immunizations
,SDP ,ssential Service Delivery Pac/age
0A*A 0ederally Administered *ri&al Areas
0BS 0ederal Bureau of Statistics
0$C0 0irst $evel Care 0acility
0P 0amily Planning
1DP 1ross Domestic Product
HI2 Human Immunodeficiency 2irus
HIS Health anagement Information System
H# Human #esource
IDUs In'ecting Drug Users
I-CI Integrated anagement of -e"&orn and Childhood Illness
I# Infant ortality #atio
I*-s Impregnated *reated -ets
$B $ive Births
$H2 $ady Health 2isitor
$H! $ady Health !or/er
3, onitoring and ,valuation
CH aternal and Child Health
D1s illennium Development 1oals
# aternal ortality #atio
-CH aternal4 -e"&orn and Child Health
)H inistry of Health
*B0 edium *erm Budgetary 0rame"or/
*D0 edium *erm Development 0rame"or/
-CD -on5Communica&le Diseases
-1) -on 1overnmental )rganization
-!0P -orth !est 0rontier Province
))P )ut of Poc/et
PHC Primary Health Care
PHDC Provincial Health Development Center
PDC Pa/istan edical and Dental Council
P#C Pa/istan edical and #esearch Council
iii
P-C Pa/istan -ursing Council
PPP Pu&lic Private Partnership
PP#A Pu&lic Procurement #egulatory Authority
P#SP Poverty #eduction Strategy Paper
PS$ Pa/istan Social and $iving Standard easurement Survey
#HC #ural Health Centre
SA#S Severe Acute #espiratory Infection
SBA S/illed Birth Attendance
S*I Se.ually *ransmitted Infections
*B *u&erculosis
*H, *otal Health ,.penditure 6&oth pu&lic and private7
*H( *ehsil Head (uarter
U8# Under five ortality #ate
U- United -ations
!H) !orld Health )rganization
!*) !orld *rade )rganization
iv
#ontents
$% &eed for a &ew Health Policy
2% The State of Pakistan's Health
a% Health System Performance
!% Health Sector inancing
c% Health Sector Management and Governance
d% Monitoring( eval)ation and s)rveillance systems
*% "ssessment of progress of implementation of Health policy 200$
+% S)mmary of ,ey #hallenges in the Health Sector
-% )t)re .irection / Stepping Towards Better Health
a% Principles
!% 0ision
c% Goal
d% Policy 1!2ectives
e% Strategic Priorities
3% 4es)lts and indicators of s)ccess
5% Translating policy into action
6% "nne7)re
v
vi
Vision
A health system that:
is efficient, equitable & effective
to ensure acceptable, accessible & affordable health services.
It will support people and communities
to improve their health status
while it will focus on addressing social inequities
and inequities in health
and is fair, responsive and pro-poor,
thereby contributing to poverty reduction.
By considering 2006-07 as the benchmark year for the National Health Policy 2009, the
goernment of Pakistan, by 20!", is committed to#
• ave additional !"",""" lives of children#
• ave additional $%,""" lives of mothers#
• &radicate polio#
• &liminate measles and tetanus#
• 'revent additional ( million children from becoming malnourished#
• 'rovide s)illed birth attendance to more than %.* million pregnant women#
• &nsure provision of family planning services to additional ( million couples.
• Avert +* million of new ,- cases#
• Immuni.e more than $$ million children against /epatitis - and other vaccine
preventable diseases# and
• 0each %" million poorest people of 'a)istan to ensure provision of essential
pac)age of service delivery.
Draft National Health Policy 2009
Pakistan's &ational Health Policy82009
Stepping Towards Better Health
9% &eed for a &ew Health Policy
9: The &ational Health Policy 2009: ;Stepping Towards Better Health; outlines a
shared resolve to ensure progress to"ards a healthy Pa/istan in "hich all citizens &enefit from
a &etter "or/ing health care delivery system4 particularly the poorest: *he Policy &uilds upon
the -ational Health Policy <==9 + *he !ay 0or"ard 5 under "hich modest progress "as
made: *here "as a felt need to reset the strategic direction due to> a7 slo" progress in
improving health outcomes? &7 inadequate sector performance in improving coverage and
access to essential health care services especially for the poor? and? c7 lac/ of synchronization
of various policy documents and their lin/ages "ith illennium Development 1oals
6D1s7: *he inistry of Health initiated the process to develop a ne" health policy in <==@
&ut the process remained slo": *he ne" 1overnment as part of its manifesto decided to set a
ne" agenda to improve health care: *he process included formulation of a Health Policy *as/
force including si. "or/ing groups "hich too/ stoc/ of the present situation and outlined the
future course of action: *he recommendations of the "or/ing groups4 consultation "ith /ey
sta/eholders and strategic directions from parliamentarians and top management in inistry
and Departments of Health contri&uted significantly to the development of ne" policy:
99% The State of Pakistan's Health
<: Human development is the &asic right of every individual and health is a pre5
requisite for the economic development: Health is an entry5point to"ards prosperity and
reducing poverty: *he lin/s &et"een ill health and poverty are "ell /no"n: Ill health
contri&utes to poverty due to Acatastrophic costs
9
A of illness and reduced earning capacity
during illness: Poor people suffer disproportionately from disease and are at higher ris/ of
dying from their illness than are &etter off and healthier individuals: !omen and children are
particularly vulnera&le: Illness /eeps children a"ay from schools4 decreasing their chances of
productive adulthood:
B: It is4 therefore4 critical to move to"ards a system "hich is a&le to address the
challenges and prevents households from falling into poverty: In Pa/istan4 health sector
investments are vie"ed as part of the governmentCs poverty alleviation endeavor: *o ma/e
progress to"ards achieving the D1s is a national commitment "hich envisages reducing
poverty &y <=98:
D: *he health of the people of Pa/istan has improved since 9EE=? ho"ever the rate of
improvement in health outcomes has &een slo" compared to its neigh&oring countries:
Pa/istanCs under5five mortality remains the highest among the South Asian countries: High
9
> An adverse health shoc/ that necessitates 9=F of household income in medical e.penses:
9
Draft National Health Policy 2009
maternal mortality 6deaths7 com&ined "ith high fertility results in one out of every GE "omen
dying from pregnancy related causes: alnutrition remains "idespread and unaddressed: In
addition4 persisting &urden of infectious diseases is no" compounded &y increasing &urden of
non5communica&le diseases:
8: Pa/istanCs population gro"th rate has declined from BF in the late 9EG=Cs to the
present estimated level of 9:EF per annum4 &ut it remains unaccepta&ly high: In <==E4
Pa/istan is the si.th most populous country in <==E4 as its population increased from 998
million to over 9H= million people in <==E: *he population is pro'ected to &e <9= million in
<=<8 and according to a United -ations 6U-7 estimate Pa/istan "ill &ecome the fourth most
populous country in the "orld &y the year <=8=4 "hich may lead to increasing scarcity of
resources and food: $ife e.pectancy at &irth4 "hich "as BD years in 9E89 and 8E years in
9EE=4 has increased to @8 years in <==8 "ith no gender disparity:
@: High fertility translates into D:< million ne" &irths every year i:e: 9948== children are
added every day to Pa/istanCs population: Ho"ever4 a&out E== infants die every day4 of "hich
@<8 are less than one month of age and B< ne"&orns &a&ies &ecome motherless due to
maternal deaths: Compared to 949D= children less than 8 years old dying every day in 9EE=4
currently 94=G= children die every day: In addition4 the latest evidence indicates that the
poorest population 6quintile7 has seen almost no change in its under58 mortality rate since the
early 9EE=Cs: 1ender does not appear to &e an important determinant of child mortality in
Pa/istan: -ational surveys indicate that girls in Pa/istan display the e.pected &iological
advantage in infant mortality i:e: G= male infants dying compared to HB female infants per
9=== live &irths Ho"ever4 gender remains an important determinant in child care e:g:
compared to 9== &oys only GG girls are fully immunized: :

H: aternal mortality and mor&idity is difficult to measure &ut availa&le evidence
indicates Pa/istan has made some improvements in recent years: In 9EE=4 8= pregnant
"omen died out of E4D8= "omen giving &irth every day4 ho"ever4 currently4 B< pregnant
"omen are dying out of 9948== "omen giving &irths every day: S/illed &irth attendance
6SBA7 has improved from 9GF in late 9EE=sC to B@F in <==@I=H: B4D== out of E4D8= &irths
ta/ing place every day are performed &y s/illed &irth attendants: Institutional deliveries have
also increased "ith B=== &irths ta/e place in a pu&lic or private health facility: Despite
improvements4 Pa/istan is still far &ehind from other countries "ith significant variations
<
Draft National Health Policy 2009
among provinces and districts4 highlighting the need to rapidly e.pand the use of s/illed &irth
attendants and deliveries in health facilities:
G: Pa/istan is having the largest ever cohort of the youth population: *he ongoing
demographic transition
<
has provided an opportunity to convert it into a Jdemographic
dividend
B
C: Ho"ever4 this opportunity "ill &e lost4 if the fertility rate is not &rought do"n at a
more rapid pace: Pa/istanCs contraceptive prevalence rate 6CP#7 has improved since 9EE=4 &ut
has stagnated during last fe" years "ith less than one third of couples use contraception "ith
only one in five use modern methods: *he unmet demand for family planning persists a&ove
B=F "ith high rates of a&ortion "ith significant ur&an rural differential: In addition4 high
rates of a&ortion imply that "omenCs lives are at ris/ from unsafe a&ortions:
E: Pa/istan has the lo"est prevalence of under5"eight in South Asia "ith the e.ception
of Sri $an/a4 ho"ever4 the prevalence has not changed much since 9EE= "ith more than E
million malnourished children: It is unli/ely that Pa/istan "ill achieve the D1 target 9B:
alnutrition increases the ris/ of dying in childhood &ut also impairs learning a&ilities and in
long run decreases the productivity of adult "or/force: *his is further complicated &y
"idespread micronutrient deficiencies significantly more prevalent in "omen and the poorest:
A&out 9= million of children under58 years4 E:< million of child &earing age "omen suffer
from anemia as a result of iron deficiency4 @:D million children suffer from reduced gro"th
and intellectual capacity as a result of iodine deficiency: In Pa/istan4 9=:8 million children and
98 million child5&earing age "omen have zinc deficiency: :
9=: *he &urden of diseases 6BoD7 is heavily dominated &y communica&le diseases4
reproductive health and malnutrition issues accounting for 8=F of the total &urden of
diseases: *his is further complicated &y &urden due to non5communica&le disease group
dominated &y cardiovascular diseases4 dia&etes4 in'uries and neuro5psychological diseases:
*his dou&le &urden of disease is a ma'or challenge in the health sector of Pa/istan: In <==<
ma'or causes of mortality and mor&idity in Pa/istan are summarized in graphs &elo":
Ischemic heart disease account for 99F of deaths4 &ut only 8F of years of life lost as many
people "ho died of the disease did so at an advanced age: Considering Disa&ility ad'usted life
years 6DA$%s
D
74 communica&le diseases form the dominant share in the &urden of diseases4
"hich can &e prevented at relatively lo" cost: #espiratory infections and diarrhoeal diseases
are still the ma'or /iller diseases in Pa/istan:

<
> *he transition in a country from equili&rium of high fertility and high mortality4 through a period of rapid gro"th4 to a period
of declining mortality coe.isting "ith continuing high fertility4 to an ultimate equili&rium of lo" fertility and lo" mortality:
B
> A phenomenon "hich occurs in the last stages of the demographic transition4 "hen changes in the population structure
6decline in dependent population and increased proportion of the "or/ force population7 create an opportunity for economic
&enefits to individuals and the country:
D
> A summary measures that com&ine information on mortality and non5fatal health outcomes to represent the health of a
particular population as a single num&er:
B
Draft National Health Policy 2009
99: Pa/istan is still one of the four remaining countries4 "here polio is endemic and 99G
cases have &een reported in <==G: Hepatitis is an endemic disease in the general population
"ith a&out 9= million carriers of hepatitis B 3 C in the country: *u&erculosis 6*B7 in Pa/istan
ran/s @th amongst the << countries4 "ith high &urden of *B in the "orld: *B is responsi&le
for 8:9 percent of the total national disease &urden and there are a&out <8=4===5B==4=== ne"
cases in the country every year: Pa/istan is a malaria endemic country "ith little change in the
status over past five years: Pun'a&4 -!0P and Sindh have lo" endemicity of malaria &ut
Balochistan and 0A*A are high endemic areas: An emerging communica&le disease challenge
is the Aconcentrated epidemicA for Human Immunodeficiency 2irus 6HI27 disease among
vulnera&le populations particularly among In'ecting Drug Users 6IDUs7: *he evidence
indicates increasing prevalence of HI2 among IDUs 6e:g: B=:8F in Hydera&ad and <BF in
Karachi7 and slo"ly increasing prevalence in male se. "or/ers in Karachi 6B:9F7 and Hi'ras
in $ar/ana 6<H:@F7: Halting its spread to &ecome an epidemic in the general population is a
ma'or challenge in coming years: In addition4 there are other emerging communica&le
diseases 6e:g: avian influenza 6AI74 severe acute respiratory syndrome 6SA#S74 leishmaniasis4
dengue fever4 hemorrhagic fever etc74 "hich off and on pose threat of an epidemic4
highlighting the need to strengthen the capacity for disease surveillance and immediate
response system:
9<: Pa/istan is also facing an increasing &urden of non communica&le diseases "ith
increasing life e.pectancy and high prevalence of ris/ factors: Share of in'uriesI accidents is
estimated to &e more than 99F of the total &urden of diseases and is li/ely to rise "ith
increased traffic4 ur&anization and terrorist activities: Pa/istan is among the top 9= countries
in the "orld "ith high dia&etes prevalence4 of a&out H:9F: )ne in four adults over the age of
D= years 6<@:EF7 suffers from coronary artery disease4 due to high prevalence of /no"n ris/
factors4 including smo/ing 6D9F among men over 9G years of age7? high &lood pressure 6<DF
in population over 9G years of age74 raised cholesterol 6<=F of people over D= years of age74
and over"eight 6<GF and <BF of ur&an and rural adults over 9G years of age respectively7:
9B: *he harm that to&acco use does to health is irrefuta&le: *he to&acco use 6che"ing or
smo/ing7 and inhaling ;secondhandL or side stream smo/e from cigarettes raises the ris/ of
many diseases and premature death: *o&acco use in Pa/istan is common and there are a&out
<< million smo/ers in the country and 88F of the households have at least one individual "ho
smo/es to&acco: In Pa/istan a&out 9==4=== people die annually from diseases caused &y use
of to&acco:
9D: Pa/istan has the highest level of ur&anization amongst South Asian countries
resulting from rural ur&an migration and it is e.pected that 8=F of Pa/istan total population
"ill &e living in ur&an areas &y <=<8: Sindh is already more than 8=F ur&an: *he health
outcomes in ur&an areas are &etter than rural in aggregate terms &ut poor households living in
squatter settlements have poor health outcomes equal if not "orse than rural households due
to similar issues of access to preventive and curative services in a fragmented ur&an health
care system:
Health System Performance
98: !hen Pa/istan came into e.istence in 9EDH4 the health system "as premature and
rudimentary: *he health system has e.panded gradually "ith a large net"or/ of health
facility4 "or/force and services across Pa/istan: Progress in health sector is evident from the
follo"ing fe" facts>
• In 9EDH4 there "ere <E< hospitals in the country "hich have no" increased to E<=
hospitals in the pu&lic sector and a&out G== in the private sector: *here "as hardly any
health facility in rural areas at time of independence: Ho"ever4 access to services has
D
Draft National Health Policy 2009
&een increased in rural areas "ith more than 88= rural health centers and 84B== &asic
health units &esides D4@== dispensaries and E== aternal and Child Health 6CH7 centers
in ur&an areas: *he information on private sector remains inadequate &ut a rough estimate
is that there a&out <=4=== private clinics in the country:
• Pa/istan had t"o medical colleges in 9EDH? no" there are H9 medical and dental colleges
in the country4 B< are in pu&lic sector and BE in the private sector: *he num&er of
registered doctors has increased e.ponentially from HG in 9EDH to more than 9994@==
doctors and GD== dentists including <948== specialist doctors and 89H specialist dentists:
• -ursing profession has also seen gro"th "ith 9=E schools of nursing 6H@ in pu&lic and BB
in private sector74 9D9 schools of mid"ifery4 <@ pu&lic health schools and H colleges of
nursing: ore than D@4=== nurses and D8== $ady Health 2isitors 6$H2s7 are registered
"ith Pa/istan -ursing Council 6P-C74 &ac/ed up &y a community &ased "or/force of
a&out E84=== lady health "or/ers: Pa/istan has no" initiated a Programme to deploy
9<4=== community mid"ives 6C!7 in the rural areas:
• $ife e.pectancy has increased from BD years in 9EDH to that of @8 years: Infant mortality
has reduced from a&out <<= per 9=== live &irths in 9EDH to HG per 9=== live &irths:
aternal mortality "as estimated to &e G==59=== per 9==4=== live &irths in late D=sC? &ut
is no" estimated to &e <H@ per 9==4=== live &irths:
• Smallpo. and Dracunculiasis 61uinea "orm7 "ere "ide spread "hen Pa/istan came into
e.istence? no" these diseases have &een eradicated: Pa/istan is also very close to the
eradication of Polio 6decreasing Polio cases from more than 84=== in 9EEB to 99G in <==G7
and the &urden of deaths due to Diarrhea diseases is decreasing?
• A&out 8<8 pharmaceutical units produce more than DH4=== pharmaceutical products and
medicines "orth of M9== million are e.ported every year:
• 0ederal4 provincial and district governments are implementing national health
programmes mainly focusing on cost effective interventions: Some of recent successes are
as follo"ing>
o Increase access to CH and 0P services in rural communities through e.pansion
of $ady Health !or/ers from BG4=== in <==9 to E84=== in <==G? and a&out 84===
community mid"ifes are under training &efore their deployment in their o"n
community:
o Improving immunization coverage 6num&er of children 9<5<B months fully
immunized7 to H@F in <==@5H compared "ith 8BF in <==95=<? 8@F of pregnant
"omen "ere receiving tetanus to.oid in <==@5=H as compared "ith D@F in <==9I=<?
and increase in the percentage of &irths attended &y a s/illed attendant + from 9GF in
9EEGIEE to B@F in <==@IH?
o *B Programme has recently passed the <=9= target of G8F of cases successfully
treated + GHF "ith increasing case detection to @EF in <==H 6close to <=9= target of
H=F7:
o HI2 3 AIDS prevention services provision has &een esta&lished through non
governmental organizations "ith increasing condom use &y female se. "or/ers and
reduced syringe sharing among in'ecting drug users?
9@: Despite improvements4 Pa/istanCs health sector continues to face many challenges:
*he /ey issue remains slo" progress in ma/ing progress in improving health outcomes and
the performance remains inadequate: Poor are not &enefiting from the health system "hereas
they &ear ma'or &urden of diseases: ,.panded infrastructure is poorly located4 inadequately
equipped and maintained resulting in inadequate coverage and access to essential &asic
services: Private health sector continues to e.pand unregulated mainly in ur&an areas: 0actors
contri&uting to inadequate performance of health sector are deep rooted including "ea/
management and governance4 partially functional logistics and supply systems? poorly
8
Draft National Health Policy 2009
motivated and inadequately compensated staff4 lac/ of adequate supportive supervision4 lac/
of evidence &ased planning and decision ma/ing4 lo" levels of pu&lic sector e.penditures and
its inequita&le distri&ution: In addition to factors internal to the sector4 e.ternal factors also
contri&ute to poor health outcome including illiteracy4 unemployment4 gender inequality4
social e.clusion4 food insecurity4 ur&anization4 environmental dangers4 lac/ of access to safe
drin/ing "ater and inadequate sanitation:
Health #are inancing
9H: Pa/istan continues to spend less on health than most other countries at the same level
of 1ross domestic product 61DP7: )ver the last 98 years pu&lic health e.penditures have
increased &y 8=F in nominal terms4 ho"ever ta/ing into account population increase and
inflation4 the real e.penditures as percentage of
1DP have stagnated at =:@F: During last five
years 6&et"een <==9I=< and <==8I=@7 pu&lic
sector investment increased &y E=F in real
terms as compared to &y 8F during the
previous 8 years4 &ut this increase also did not
meet the targets set under Poverty #eduction
Strategy and 0iscal #esponsi&ility Act: ost
6H8F7 of the health e.penditure is out of
poc/et 6))P7: *his com&ined "ith lac/ of
social protection mechanism puts large num&er
families at ris/ of poverty &ecause of illness:
9G: *he federal and provincial governments have &een a&le to secure internal resources
for the health sector in recent years: Ho"ever4 the 1overnment has mo&ilized fe" e.ternal
resources for the sector from development partners4 private sector or philanthropic sector: A
rough estimate indicates that Pa/istan mo&ilizes only a&out HF of total e.penditure from
e.ternal sources4 "hen the average for lo" income counties is a&ove 9DF and in Bangladesh
it is more than <<F:
Health Sector Management and Governance
9E: Pa/istan has a mi.ed health care delivery system including &oth state and non5state
providers and for profit and not for profit: *he inistry of Health4 provincial and district
health departments4 parastatals4 social security4 non5governmental organizations 6-1)s7 and
private sector finance and provide services mostly through vertical mechanisms:
<=: *he federal4 provincial and district governments have clear roles and responsi&ilities4
&ut there are overlapping functions in practical terms: *he role of the federal government
relates to policy formulation4 provision of technical &ac/stopping4 coordination "ith different
partners "ith in and outside the country4 communica&le disease control and financing for
health care: Ho"ever an overemphasis of the inistry of Health to"ards national
programmes has diminished its ste"ardship roles of policy ma/ing4 regulation4 monitoring 3
evaluation 6including surveillance7 for quality of care and health care financing: Provincial
departments of health are responsi&le for translating the national policy into planning and
implementing it4 through generating the required human resource4 providing specialized care
through its tertiary care hospitals4 &esides overseeing primary and secondary health services
provided &y the district governments:
<9: *he actual service delivery ta/es place at the district level "here the t"o tiers of
primary and secondary health outlets are managed: *he districts also run the federally
financed national health programmes that &ring a dichotomy in the management due to its
dual command mechanism: All the preventive services are implemented at the district level
@
Draft National Health Policy 2009
"here government is more or less the sole provider4 &esides the provision of medico5legal
services:
<<: Despite devolution of po"ers at the local level4 the health system remains centralized
and not a&le to respond to the organizational and governance challenges resulting in
ineffective use of already scarce resources and its a&ility to deliver: *he management
challenges arise due to multiple supervisors4 lac/ of clear roles and responsi&ilities in three
level of government and multiple directions coming from different levels: Devolution remains
incomplete "ith "ea/ accounta&ility mechanisms and management capacity at the district
level: *he pu&lic health system needs re5organization &ased on management principles4 "ith
the federal and provincial governments focusing on its core ste"ardship functions of policy4
regulation4 monitoring and evaluation4 standard setting and moving to"ards quality service
delivery &oth &y the pu&lic and private sector:
Monitoring( <val)ation and S)rveillance systems
<B: onitoring 3 evaluation and surveillance culture remains "ea/ at all levels due to
an a&sence of result &ased culture: Information systems are present in most 0irst level care
facilities 60$C0s7 and in national programmes4 so a culture of continuous data reporting
e.ists: Currently4 these systems are highly fragmented and often vertical leading to
duplication of efforts: Health anagement Information System 6HIS7 developed during
early 9EE=Cs is functional &ut there are significant issues: Data quality4 its accuracy and
completeness is compromised and use of information for decision ma/ing is discretely
practiced: In addition it failed to evolve to develop other information su& systems initially
envisioned e:g: human resource 6H#7 information system: *he pu&lic hospital system in
Pa/istan lac/s a standardized information system and most maintain their o"n information
system "ithout a regular reporting mechanism: *here is also no system to gather information
from large private sector for the state to underta/e its function to protect pu&lic interest: *he
a&ove situation of information systems is a direct result of "ea/ institutional mechanism for
monitoring and evaluation 63,7 including lac/ of o"nership and organization support for
data and information: 0ederal and provincial governments no" focus almost entirely on
routine data coming from health management information systems and data from household
surveys are not fully used: Pa/istan has not underta/en a national health survey for more than
decade:
<D: onitoring and evaluation are /ey federal and provincial responsi&ilities and careful
attention to its operation5a&ility "ill &e critical for enhancing accounta&ility and to ma/e the
system result oriented: *he inistry of Health has ta/en steps to strengthen 3, including a
detailed assessment of HIS? design and assessment of District Health Information System
6DHIS7 including the hospital sector? DHIS has &een piloted and "or/ is in progress to
initiate its implementation across Pa/istan? use of third party to evaluate programmes and a
performance assessment of the health sector disaggregated &y provinces and districts to
facilitate policy development and informed decision ma/ing: *he performance assessment
used analysis of secondary data for intermediate health outcomes generated from Pa/istan
Social and $iving Standards easurement 6PS$7 Survey: *hese are steps in the right
direction &ut there is more to &e done to generate information to facilitate informed decision
ma/ing:
<8: A critical aspect under the 3, and ste"ardship function is to ensure having an
effective health surveillance system "hich is needed for effective prevention and disease
control measures: Pu&lic health surveillance is a recognized pu&lic good and responsi&ility of
the state: Ho"ever4 Pa/istan at present has vertically operating multiple small initiatives in
surveillance "ithout a system "hich is not in a state to generate good quality information for
ma/ing /ey pu&lic health decisions: *he fragmentation is a result of lac/ of organizational
unit or structure at the federal provincial and district level responsi&le for surveillance4 lac/ of
H
Draft National Health Policy 2009
legal frame"or/ for disease reporting and lac/ s/illed manpo"er and resources for this
important function: In addition4 no pu&lic health la&oratory net"or/ e.ists e.cept a Pu&lic
Health Division $a&oratory in -ational Institute of Health: *he inistry of Health is
cognizant of the situation and undertoo/ a detail assessment: A detailed frame"or/ has &een
developed &ut not put in place: Some aspects of the plan are &eing implemented e:g: A
training programme through 0ul&right fello"ships for researchers4 and communica&le
diseases control has &een started to produce s/illed manpo"er for surveillance: *his "ould
entail development of a comprehensive system and &uild organizational capacity at federal4
provincial and district levels for its effective functioning:
Pharmace)ticals Sector
<@: At the time of independence4 Pa/istan had no pharmaceutical manufacturing unit and
pharmaceutical needs "ere met through imports: *he local pharmaceutical industry developed
over time responding to indigenous demand gro"ing to a size of a&out #s: GG &illion 69:<
&illion M7 "ith e.port of US M 9== million annually 6=:<<F of glo&al pharmaceutical mar/et7
in <==H: *he Pa/istani mar/et is shared equally &y local manufacturers and multinationals:
*here are DH4=== products registered "hich are &eing produced &y 8<8 companies including
B= multinationals:
<H: *he pharmaceutical sector is regulated under the Drug Act 9EH@: Historically drug
prices "ere fi.ed &y the inistry of Health on case to case &asis under the Drug Act:
Ho"ever4 since 9EEB4 partial deregulation 6B<B molecules 3 G<9 formulations7 "as approved
thus reducing the po"ers of the inistry to regulate drugs4 resulting in an e.traordinary
increase in prices: *he decision "as put on hold in 9EED4 "hich is still in place: *he cost
issue "as also addressed partially through the introduction of 1eneric Drug Act 6in 9EH<4 HB74
&ut it "as not implemented and the commercial interests of sta/eholders forced the policy to
&e reverted: *he situation calls for an appropriate mechanism for drug pricing "ith an in&uilt
monitoring mechanism:
<G: As drug procurement constitutes the ma'or portion of health e.penditure 6mainly out
of poc/et7 and main contri&utor to the catastrophic health e.penditure4 an annual revie" of
pricing &ased on the input cost can &e &eneficial to the patient as "ell as the industry: *his
calls for a pro poor drug policy that maintains prices "ith in the reach of the people at least of
essential medicines4 focusing on quality4 accessi&ility and afforda&ility: *he availa&ility of
over the counter sale of drugs and over prescription &y physicians due to unethical mar/eting
practices is increasing the cost of treatment &esides giving rise to drug resistance:
<E: *here is a flourishing alternate health care4 her&al and other medicines
6homeopathic4 ayurvedic etc7 mar/et "ith little control: An effective approach is &ringing
these her&al and other alternative drugs under registration and quality inspection domain:
B=: *he increasing num&er &rands in the mar/et has generated a never ending
competition that compel the manufacturers for unethical promotions and mar/eting tactics4
"hile on the other hand certain in5e.pensive and less profita&le medicines 6some very
essential7 are not manufactured locally and the government has no &inding on the
manufacturers to ensure the availa&ility 6manufacturing7 of these in5e.pensive essential drugs:
Although the government "ould &e "illing to loo/ after the interests of pharmaceutical
industry for economic reasons and e.port potential4 &ut access to essential drugs is an
important component of health care and health outcome? and it is imperative that the
government maintains regulating the drug sector4 of course not each and every formulation:
B9: inistry of Health has developed essential drugs lists for different levels of health
care facilities and hospitals &ut in practice these guidelines are not follo"ed completely: *here
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Draft National Health Policy 2009
is also need of rational use of drugs at the service delivery level "hich can only &e ensured
through a mechanism of supervision4 availa&ility of treatment protocols and appropriate
training: *he procurement of drugs at federal level is &eing no" underta/en according to the
Pa/istan Procurement #egulatory Act 6PP#A7: *he procurement process and testing of drug
quality is functional &ut the system needs to &e strengthened in terms of its effectiveness and
timeliness: In addition4 the process of procurement at all levels has limited internal controls
and monitoring mechanism to ensure value for money &eing spent:
Medical <d)cation
B<: At the heart of each and every health system4 the "or/force is central to advancing
quality of health care: At the time of independence in 9EDH4 Pa/istan inherited a "ea/ health
sector having fe" health esta&lishments and limited avenues for production of doctors and
paramedics "ith only t"o medical colleges: Investments during the last three decades have
seen considera&le improvement in the production capacity of health care providers: But the
focus on human resource development remained un&alanced and lopsided "ith inadequate
emphasis on nursing and paramedical education "ith significant negative impact on quality of
health care: Pa/istan is among the countries that still has critical shortage of health "or/force:
*here is no "ell5defined policy 3 plans for human resource development in the health sector:
*he inistry of health and the departments of health lac/ organizational structures
responsi&le for human resource development: A num&er of critical issues limit quality of
manpo"er produced including> curricula for the health manpo"er do not match local health
needs? ,ducational institutions are ill equipped to provide quality education using o&solete
traditional instructional methods and curricular formats resulting manpo"er not competent
enough to function effectively in primary and secondary levels of health care settings: *here
is inadequate emphasis on use of information technology4 in communication methods4
medical ethics4 or the &io5psycho5social model of health: #e5orientation of medical education
and curricula to address the a&ove challenges &esides focusing on pu&lic health4 prevention
and promotion of health:
BB: *he mechanism for induction courses for different cadres in the health sector is not
in place "ith very fe" such activities carried out &y isolated pro'ects: *he in5service training
mechanism through Provincial Health Development Centers 6PHDC7 and District Health
Development Centers 6DHDCs7 introduced during 9EE=Cs is partially functional: Similarly
there is no formal policy4 national standards or guidelines for structured implementation to
update /no"ledge and s/ills of health care providers4 including programmes for continuing
medical education and systems of re5accreditation of doctors4 nurses and paramedics: )ther
critical areas in "hich there is shortage of s/illed health "or/force include hospital
management and management of health systems: Achieving the D1s "ill depend on
finding effective human approaches that can &e implemented rapidly: Systematic thin/ing in
several areas is required to formulate "ays of recruiting and retaining health "or/ers "ith
opportunities for career development:
999% Progress of 9mplementation of Health Policy 200$
BD: #evie" of the <==9 policy indicates progress has &een made in achieving the targets
despite significant challenges: *he revie" of health sector performance in light of D1s or
Poverty reduction strategy papers 6P#SP7 monitor5a&le indicators indicates that Pa/istan is
moving in the right direction4 even though the pace is slo": *his is evident from declining
infant 3 child mortality and fertility etc: Ho"ever4 in depth analysis indicates that this policy
is inefficient in terms of resource usage for policy o&'ectives4 ineffective in terms of
producing a measura&le impact on intended &eneficiaries and inequita&le in terms of
&enefiting relatively more ur&anites and is gender insensitive: *he pu&lic sector services
E
Draft National Health Policy 2009
utilization has not changed much: Critical issues related "ith the health policy <==9 are
summarized &elo">
i: *he inter5lin/ages of the health policy <==9 "ith P#SP4 D1s and *D0 are not
e.plicitly "ell defined? the policy is not fully synchronized "ith the id *erm
Development 0rame"or/ 6*D074 Poverty #eduction Strategies Papers 6P#SP74
illennium Development 1oals 6D1s74 provincial level strategic frame"or/s and
medium term &udgetary frame"or/ 6*B07 processes:
ii: -o targeting strategy "as envisaged to ensure pro5poor healthcare interventions?
iii: *he policy lac/ed e.plicit monitoring and evaluation frame"or/ to assess results under
each goal of the policy:
iv: $ittler emphasis on advocacy and orientation for the policy ma/ers in terms of role of
health in reducing poverty and producing high quality human capital resulting in lo"
financial allocation for health as compared to other sectors:
v: *he policy "as almost silent on e.panding and increasing role of the private sector:
vi: *o some degree it failed to strategize ho" financial as "ell as non5financial gap "ill &e
met and did not envisage alternate healthcare financing sources as option:
B8: In summary4 although the health of the population in Pa/istan has improved4 the pace of
improvement has not &een satisfactory: *he e.isting health care system has not delivered up
to the full e.pectation of the people due to various reasons:
9=
Draft National Health Policy 2009
90% S)mmary of ,ey #hallenges in the Health Sector:
B@: In summary4 key challenges in the health sector are>
i: a/ing progress in current health sector programmatic reforms to achieve D1s and
tac/ling effectively ne"ly emerging and re5emerging health issues including non5
communica&le diseases and disasters
ii: Improving access of essential and cost effective health services especially for the poor
and vulnera&le
iii: ,mphasizing more on quality of care and services at all levels
iv: Protecting poor from catastrophic health e.penditures
v: Improving the institutional arrangements and management of health care delivery
system
vi: Improving the availa&ility 6specially female7 and motivation of health "or/force
vii: Aligning outputs of the academic institutes in line "ith the needs of health system and
improving the quality of education and training:
viii:,ffectively engaging private health sector and civil society organizations to improve
health outcomes
i.: Developing pharmaceutical sector and ensuring access to quality medicines
.: a/ing health system more responsive and accounta&le
.i: ,nsuring effective research4 monitoring 3 surveillance system to measure results and
evidence &ased decision ma/ing at all levels
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Draft National Health Policy 2009
0% )t)re .irection / Stepping Towards Better Health
BH: Principles: Health is an essential prerequisite "ithout "hich individuals4 families4
communities and nation cannot hope to achieve their social and economic goals: *he ne"
policy paradigm is &ased on health as a right as envisioned in the Constitution of Pa/istan and
"ill &e driven &y the follo"ing /ey principles>
i: ,nsuring universal coverage of an essential pac/age of health interventions "ithout
economic4 geographical4 social or cultural &arriers and is responsi&ility of the state?
ii: )vercoming social and economic inequities to improve health outcomes?
iii: Promotion of a results &ased culture ensuring a shift from a planning environment
concentrated on the reporting of processes and outputs to outcomes?
iv: Provision of quality health care and ensuring gender sensitive and patient5centered
services?
v: ,nsuring good governance4 promotion of meritocracy and transparency in every
aspect of health care management? and
vi: Promoting evidence &ased decision ma/ing "hich must prevail at every level of the
health system so that policy development and actions deriving from policies are
relevant4 feasi&le4 resource appropriate and culturally and socially accepta&le:
BG: *he principles are envisaged to &e applied to all aspects of health care and "ill &e
supported &y emphasis on local 6district7 o"nership and leadership4 strategic coordination4
&uilding local capacity4 and e.panding partnership "ith private sector:
BE: 0ision: *he Policy envisages a long term vision to reorient the health system
endorsing the concept of health for all strategy al&eit 5 a health system that: is efficient,
equitable & effective to ensure acceptable, accessible & affordable health services. It will
support people and communities to improve their health status while it will focus on
addressing social inequities and inequities in health and is fair, responsive and pro-poor,
thereby contributing to poverty reduction.
D=: Goal> *he overall goal of the policy is to improve health status of the people of
Pakistan:
D9: Policy 1!2ectives:
-ational Health policy aims to improve health status of people of Pa/istan &y achieving the
policy o&'ectives mentioned &elo" and it is envisaged that it "ill also help Pa/istan to ma/e
progress to"ards health related D1s:
i: ,nhancing coverage and access of essential health services especially for the poor?
ii: easura&le reduction in the &urden of diseases especially among vulnera&le segments
of population?
iii: Protecting to the poor and under privileged population su&groups against catastrophic
health e.penditures and ris/ factors?
iv: Strengthening health system "ith focus on resources?
v: Strengthening ste"ardship functions in the sector to ensure service provision4
equita&le financing and promoting accounta&ility?
vi: Improving evidence &ased policy ma/ing and strategic planning in the health sector:
9<
Draft National Health Policy 2009
09% Strategic priorities
D<: Addressing the gaps in the health sector requires a fundamental change in the
thin/ing that informs health policy at all levels: *he paradigm shift requires that the
o&'ectives of the health policy "ould &e to serve the needs of the people especially poor and
vulnera&le: *his implies changes in all health sector parameters> "hat health services to offer?
"ho &enefits from health services? "hat programmatic and systems reforms should &e in
place? and ho" the resource cost to &e shared: In addition4 it is critical that the federal4
provincialIarea and district governments re5affirm achieving health related D1s &y <=98: *o
transform this commitment into action4 the federal and provincialI area governments "ill
develop4 implement and monitor health sector strategic frame"or/s to achieve health related
D1s and the follo"ing policy o&'ectives of the -ational Health Policy <==E:
Policy 1!2ective $: ,nhancing coverage and access of essential health services especially for
the poor
DB: 1iven the important role of &etter health as a /ey driver of social advancement4 the
foremost policy priority is to enhance coverage and access to essential health services and
improving the quality of health care services particularly for the poor and vulnera&le
especially "omen and children: *he priority policy actions include>
Policy "ctions:
$%": Primary and Secondary Health #are acilities:
97 ,ssential service delivery pac/age "hich "ill &e a series of specific health services
and standards of care and not only a set of physical infrastructure4 staff4 equipment
and supplies 6Anne.ure III7: Both pu&lic and private sectors "ill play their role in
enhancing coverage of essential health services: Ho"ever4 delivering the essential
service delivery pac/age as a pu&lic good to all citizens through its o"n infrastructure
"ill &e ensured on priority &asis4 regardless of management arrangements:
<7 ,mphasis "ill &e to re5vitalize Primary health care 6PHC7 system "ith a focus on
reproductive health and family planning services4 integration of services4 improving
quality of care and o"nership of interventions at the local level:
B7 Availa&ility of staff 6especially female staff7 for service delivery particularly in
primary health care facilities in rural areas "ill &e ensured &y e.ploring differential
pac/ages of salaries and performance incentives:
D7 A system of supportive supervision and monitoring "ill &e revitalized at the local
level along "ith community &ased accounta&ility mechanism:
87 )utreach "or/ers 6vaccinators4 sanitary "or/ers and malaria inspectors etc7 "ill &e
converted into multipurpose health care "or/ers4 "ith their line of command at the
health facility level: -um&er of posts "ill not &e reduced &ut coverage area "ill &e
rationalized for effective delivery of multiple services "ith increase in frequency of
visits:
@7 ,very district "ill &e attached "ith a teaching institution in the provinceI area and
specialists 6initially 1yneIo&stetrician4 pediatrician4 surgical and medical specialist7
"or/ing in tertiary and district headquarter hospitals "ill have periodical visits to
remote health facilities "ith pu&licized schedule:
H7 Considering the issue of ur&anization and ur&an slums4 there "ill &e a revie" and re5
structuring of ur&an primary health care system for provision of essential pac/age of
9B
Draft National Health Policy 2009
health services especially for the poor living in ur&an slums and e.ploring the option
of pu&lic private partnership:
G7 Productive community involvement at the health facility level "ill &e strengthened to
improve responsiveness:
E7 A comprehensive referral system &oth for emergencies and normal health care
involving all levels of health care "ill &e developed and implemented:
$%B: Primary and Preventive Health #are Programmes:
1) ,ssential health services through the -ational ,.panded Programme on
Immunizations 6,PI74 the $ady Health !or/ers 6$H!s7 Programme and the -ational
aternal4 -e"&orn and Child Health 6-CH7 Programme "ill &e e.panded "ith
ma.imizing synergies &et"een these interlin/ed programmes and further reinforcing
lin/ages "ith the -utrition programme:
2) *he health sector "ill specially focus on provision of 0amily planning 60P7 services
through the healthcare net"or/ and community &ased lady health "or/ers &y> 6i7
ensuring financing and provision of at least three modern contraceptive methods and
s/illed manpo"er in all health outlets of Departments of Health 6DoHs7? 6ii7
strengthening the provision of 0P services and products through the $H!s at the
doorstep of community4 and 6iii7 0ostering greater functional integration &et"een the
t"o vertical institutional entities4 6Health and Population !elfare7 in order to
ma.imize synergies at the service delivery levels: *he main constraint to &e addressed
through a&ove measures "ill &e to ensure commodity security and availa&ility of
contraceptives in each and every health outlet:
3) In relation to maternal health4 inistry and Departments of Health "ill ensure
training and deployment of the ne" cadre of community mid"ives through -ational
-CH Programme and strengthening of round the cloc/ comprehensive and &asic
,mergency )&stetrical and -eonatal Care 6,m)-C7 services:
4) Pa/istanNs nutrition outcomes have &een relatively stagnant over the last t"o decades:
*he current glo&al increase in food prices4 "hich is affecting Pa/istan as "ell4 is
li/ely to compromise these outcomes further: *he inistry and Departments of
Health "ill develop a practical programme "ith an o&'ective of improving the
nutrition status of "omen of child&earing age and children &elo" B years &y
improving the coverage of cost effective nutrition interventions:
5) *o address the persistence challenge of child mortality at facility and community
level4 the -ational -CH and $ady Health !or/ers 6$H!7 Programmes "ill
implement standard protocols for management of common childhood illnesses at
facility and community level respectively:
6) Demand side interventions (cash transfer, vouchers scheme etc) will
be pilot tested (especially for delivery services and ! treatment)
before lar"e scale replication of such interventions#
9D
Draft National Health Policy 2009
Policy 1!2ective 2: easura&le reduction in the &urden of diseases especially among
vulnera&le segments of population
DD: Pa/istan &ears a dou&le &urden of diseases? although the &urden of communica&le
diseases4 childhood illnesses4 reproductive health pro&lems and malnutrition is high and
remains to &e tac/ed4 non5communica&le diseases 6-CDs7 are fast emerging as the ma'or
contri&utors of death and disa&ility: *he ma'or &runt of all these diseases are &orne &y the
poor O communica&le diseases and malnutrition are commoner amongst the poor and the
vulnera&le "hereas -CDs affect the economically productive "or/force4 lead to income
losses4 lost productivity and are /no"n to &e the ma'or contri&utors to health shoc/s: *he
focus of the health policy "ill therefore &e to address all these disease dimensions through
follo"ing policy actions>
Policy "ctions:

1) ,.panded Programme on Immunization 6,PI7 "ill respond to the system level
challenges &y focusing on lo" performing areas4 attempting to reduce dropouts and
improving monitoring and supervision systems: $ady health "or/ers "ill &e involved
to deliver routine immunization services in their catchmentCs areas: *he feasi&ility of
introducing ne" cost effective vaccines "ill also &e e.plored:
2) Polio eradication "ill remain the priority of the government and efforts "ill &e made
to interrupt its transmission &y <=9=: he pro"ramme will attempt to "et
around overarchin" issues, such as low covera"e of routine
immunisations, security situation in $%&'(&)) and !alochistan and
lar"e scale population movements, which are responsible for the
increase in the 'olio transmission* there will also be an emphasis on
further improvin" the +uality of the campai"n#
3) Interventions to control diseases li/e diarrhea and respiratory infections4 etc "ill &e
revie"ed for rapid e.pansion of Integrated management of neonatal and childhood
illness 6I-CI7 strategy4 incorporating ne" /no"ledge e:g: use of zinc for the
management of diarrhea:
4) he $ational uberculosis (!) ,ontrol pro"ramme will continue to
follow its strate"ic plan with a special emphasis on maintainin"
recent successes and e-pandin" uberculosis. Directly /bserved
reatment short course (! D/s) strate"y throu"h lar"e networ0 of
hospitals and wor0in" with the private sector# he challen"e to
ensure uninterrupted availability of D/s medicines will be
addressed by stren"thenin" the lo"istics and procurement system
with ade+uate 1nancin"# he pro"ramme2s strate"ic plan will be
updated based on the results of ! prevalence survey and
independent third party assessment of the pro"ramme#
5) 3n response to the endemic 4alaria burden in 'a0istan, the
pro"ramme will continue to implement the 5oll !ac0 strate"y with
e6ective implementation in hi"h ris0 districts, usin" rapid dia"nostic
0its, e-pandin" the use of impre"nated treated nets (3$s) and
usin" updated treatment protocols# 3n addition, a comprehensive
strate"y will to be developed to respond to other vector borne
diseases especially den"ue fever#
6) he $ational 738 9 )3D: ,ontrol 'ro"ramme will rapidly e-pand
preventive services for the hi"h ris0 population especially in;ectin"
dru" users, se- wor0ers and mi"ratin" population mainly throu"h
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Draft National Health Policy 2009
private and $</ sector# he focus will also be on provision of
treatment and care to the positive cases* control of se-ually
transmitted infections (:3s), ensurin" safe blood transfusion,
prevention of mother to child transmission, chan"in" behaviours to
address issues of sti"ma and discrimination and enhancin" capacity
of the implementin" partners#
=) 'rovision of safe blood will be ensured by stren"thenin" !lood
ransfusion )uthorities, revision in le"islation and vi"orous
monitorin" of blood ban0s both in public and private sector#
'rovision of safe blood durin" emer"encies and especially for
children a6ected with diseases such as thalassaemia etc will be
ensured by encoura"in" public private partnerships#
>) o address the "rowin" burden and spread of 7epatitis ! 9 ,, which
are mainly transmitted throu"h se- and blood, the $ational
'ro"ramme for 7epatitis ,ontrol will review its strate"ic plan to
focus on primary prevention throu"h e-pandin" immuni?ation for
7epatitis ! in children, vaccination of hi"h@ris0 "roups, ensurin"
provision of safe blood# ertiary hospitals will establish screenin"
and dia"nostic centres and treatment facilities#
A) %hile discoura"in" irrational use of in;ections "ivin" practices, the
use of auto destructible syrin"es will be promoted in all health
facilities, hospitals and pro"rammes in a phased manner with ban
on the use of routine syrin"es#
1B) he "overnment will develop and implement an 3nte"rated
Disease :urveillance :ystem by establishin" operational
surveillance units at all levels with s0illed sta6 and bac0up networ0s
of laboratories, ensurin" 'a0istan ful1l the re+uirements in line with
international health re"ulations# )s the system develops, e-istin"
disease speci1c surveillance activities will be inte"rated alon" with
options to include 4,7 surveillance and $,D behaviours#
11) he scope of public health interventions will be broadened to
address diseases that have remained ne"lected to date, but which
parado-ically are the leadin" causes of death and disability# $on@
communicable diseases, which include in;uries, diseases of the
heart, diabetes, cancers and chronic lun" conditions, a6ect the
economically productive wor0force, result in income loss and lost
productivity# $,D control strate"ies will be implemented focusin" on
primary prevention and reducin" ris0y behaviours includin"
smo0in", life styles and dietary habits#
12) Cmer"ency response system will be e-panded coverin" all
lar"e cities in the initial phase# )ll 7D and D7D hospitals will
e-pand services to deal with emer"ency and trauma cases# 4edical
emer"ency technician trainin" pro"ramme will be launched#
9@
Draft National Health Policy 2009
Policy 1!2ective *: Protecting the poor and under privileged population su&groups against
catastrophic health e.penditures and ris/ factors
D8: !hether it is glo&al financial crises or increased health e.penditures at household
level4 the impact on the poor and near poor is very serious4 as ris/ management options are
limited> the poor may need to sell productive assets4 nutritional standards are li/ely to fall and
the a&ility to spend on private healthcare "ill fall: 3n that situation morbidity and
mortality rates rose# In countries li/e Pa/istan4 "hen the overall economy comes under
pressure4 a common feature is that spending on private healthcare falls as people see/ to shift
to pu&lic care: *he demand for pu&lic healthcare rises significantly at precisely the time that
governments feel the financial need to cut &ac/: In such situations it is the poor "ho are
almost al"ays squeezed out: *herefore4 to protect the poor from catastrophic health
e.penditures and ris/s4 the government "ill ta/e follo"ing policy actions>
Policy "ctions:

1) *he government "ill "or/ on the concept of a -ational Health Service: *hrough this4
the government "ill ensure the poorest people to access health services and more
e.plicitly access to a doctor: *he scheme envisages using the data&ase of Benazir
Income Support Programme 6BISP7 and registering the poorest families at the level of
the union council or su& district level and issuing a health card "ith &asic health
characteristics? the card "ill also entitle citizens to services 6not provided &y the state7
through private providers: *he provider "ill refer cases of critical illness to district
level hospitals 6or "hatever higher tier that is required7: *he design4 modalities and
strategies "ill &e pilot5tested &efore nation"ide e.pansion:
2) *here "ill &e no user charges at primary level pu&lic health facilities: 0urther
emergencies services 6including medicines7 and delivery services in all pu&lic
hospitals "ill &e free of cost: #espective governments "ill determine user charges
only in referral hospitals to avoid unnecessary load of patients see/ing primary health
care: Ho"ever4 those patients referred from primary health care facilities "ill &e
e.empted of such user charges: )ther social protection initiatives 6Baat5ul5mal4 Pa/at
etc7 "ill &e made availa&le for the poor:
3) *he government "ill provide free specialized care 6dialysis services4 eye surgery4
treatment of heart diseases and other long term illness and disa&ilities7 to the poorest
people "ho are registered "ith BISP:
4) Cash transfer and vouchers schemes "ill &e tested &efore large scale replication to
protect poor from catastrophic e.penditures
5) Access to essential drugs "ill &e ensured in all pu&lic health facilities and hospitals:
Pharmacy &an/s for the poor "ill &e tested in selected hospitals: 0ree medicines for
the treatment of *B4 AIDS and alaria "ill &e made availa&le:
6) o avoid health ris0s and promote better health, 4inistry and
Departments of health will develop comprehensive inte"rated
behaviour chan"e communication strate"y, which will focus on the
needs of the poor and vulnerable#
=) 7ealth insurance models will be piloted to create a mar0et which
may later on be e-panded to the poorest se"ments with
"overnment( ?a0at sharin"#
9H
Draft National Health Policy 2009
Policy 1!2ective +: Strengthening health system "ith focus on #esources
D@: In health sector4 access to health care provider and access to medicine are the t"o
ma'or demands of the people: Health systemCs ste"ardship functions on human resources and
medical products 6including medicines7 "ill &e a priority through follo"ing policy actions:
Policy "ctions:
+%": Health =orkforce
97 *he government "ill develop a comprehensive health "or/force policy &y <=9=4
&ased on o&'ective assessments of needs: *he government "ill also enact a health
"or/force la" encompassing all categories of health care providers4 defining career
structures4 laying do"n service4 promotion and recruitment rules and revie"ing
cadres to avoid duplication and promoting multipurpose s/illed "or/ers:
<7 #ole of health "or/force accreditation &odies + Pa/istan edical 3 Dental Council
6PDC74 Pa/istan -ursing Council 6P-C7 + "ill &e strengthened? "hereas the
government "ill revie" the option of esta&lishing a ne" accreditation &ody for health
technicians and paramedics:
B7 *he government "ill &alance out the mi. of health "or/force considering the needs
of the health system: Current shortfall in certain categories e:g: nurses4 mid"ivesI
$ady health visitors 6$H2s74 specialized technicians4 health systems and hospitals
managers4 researchers etc4 "ill &e addressed:
D7 A separate management cadre 6"ith equal opportunities for females7 at all levels "ill
&e developed in the pu&lic sector:
87 Selection and appointment of health "or/force "ill &e &ased on merit and having
competencies fit for the post: As system to measure performance and competencies of
health "or/force "ill &e developed:
@7 Staff vacancies "ill &e filled on priority &asis and the issue of shortage of female
health care providers and nursing staff especially in rural areas "ill &e addressed:
H7 Staff 6especially in rural areas7 "ill &e employed on terms and conditions that aid
recruitment4 equita&le deployment4 retention and high performance:
G7 Due attention "ill &e paid to recruit and retain "omen health "or/force &y creating
fle.i&ilities and providing opportunities for gro"th:
E7 All health departments "ill maintain data&ase of health "or/force appointed in the
pu&lic sector: -o posting4 transfer or deputation "ill &e made "ithout feeding the
information in the health data&ase:
9=7 Dual 'o& holdings "ill &e discouraged other than institutional practice after "or/ing
hours:
997 At least t"o years "or/ing at BUHI #HC "ill &e compulsory for post graduation and
for appointment as a specialist in the pu&lic sector:
9<7 Competency &ased training "ill &e promoted in all medic and paramedic health
institutions:
9B7 Health institutions "ill esta&lish a mechanism of continued education for all cadres of
health "or/force: System of continuing education i:e: Provincial Health Development
Centers 6PHDC7 and District Health Development Centers 6DHDC7 "ill &e
revitalized:
9D7 1eneral practitioners "ill &e offered post graduate level training opportunities in
family medicine in addition to refresher training courses on technical health issues:
9G
Draft National Health Policy 2009
+%B: Pharmace)ticals and Medical prod)cts
97 inistry of Health "ill announce a ne" prop5poor -ational Drugs Policy:
<7 A -ational Drugs #egulatory Authority "ill &e esta&lished that "ill "or/ on the
principle of rationalizing rather than directly regulating the entire array of D<=== plus
drugs registered in the country: *he prices of only essential drugs need to &e
regulated4 "hile prices of non5essential medicines should &e monitored:
B7 Pharmaceutical product dossier at the time of registration "ill &e simplified and
&rought in conformity "ith regional standards: Sta&ility testing procedures "ill also
&e standardized on the &asis of &est practices in the region: Cost effectiveness of
drugs "ill &e included as a criterion in the process of registration:
D7 It is in the interest of registered manufacturers to maintain quality standards if they
"ant to capture larger mar/et shares and &rea/ into e.port mar/ets: An institutional
mechanism of pu&lic5private partnership for quality chec/s "ill &e devised "here the
private sector and civil society "ill also participate in instituting regionally accepta&le
quality standards for medicines and other products:
87 -ational #egulatory Authority "ill &e &rought up to the standards of !H)4 so that it
may also facilitate production of quality &iological products 6vaccines4 sera and anti5
sna/e venom4 antiviral etc7 in the country:
@7 !hile drug inspection is a provincial su&'ect4 high level of variation e.ists in
inspections across provinces: Provinces "ill create appropriate protocols for
inspection4 in terms of quality and quantity of inspections: $egislation "ill also &e
done to give more po"ers to inspectors and for appropriate documentation on
inspections and their outcomes:
H7 Provincial (uality Control Boards "ill &e esta&lished and strengthened: !hile there
"ill &e a need for more la&s in the future4 as a policy4 e.isting quality control la&s "ill
&e strengthened and their a&ility to carry out ro&ust chec/s "ill &e ensured: *he
quality control la&oratories "ill come up to regional standards for validation: !H)
"ill then carry out validation inspections of the la&oratories: )nce the la&s are
validated4 the !H) "ill carry out annual audits to ensure quality:
G7 )ne mechanism for chec/ing counterfeit and spurious drugs is to &ring in her&al and
other alternative medicines under the registration and quality inspection am&it:
$egislation in this regard "ill &e put through to the parliament for approval:
E7 #ational use of drugs "ill &e promoted: 0or this purpose4 a three pronged approach
"ill &e revie"ed> i7 legislation "here&y superfluous or e.cessive use of drugs &y
doctors can &e challenged &y the patient4 ii7 appropriate legislation and enforcement
mechanism can &e devised to limit over the counter drug availa&ility4 iii7 )ver time
the requirement of a qualified chemist at every drug outlet can &e introduced: *his
policy action "ill have to &e phased out to ensure that enough pharmacists are
produced in the country and present in different parts of the country: Initially this
policy can &e introduced and enforced in large ur&an centers of the country:
9=7 *he supply of essential drugs to the appropriate facility "ill &e on the &asis of
specific services provided &y the facility as against the present practice of supplying
drugs on the &asis of demand from the facility: Drug requirement for each tier of
service provision "ill &e determined specifically:
997 *o chec/ against pilferage and "astage4 standard treatment guidelines at different
tiers of health facilities "ill &e made operational in the procedure of procurement and
dis&ursal of drugs:
9E
Draft National Health Policy 2009
9<7 inistry of Health4 Provincial Health Departments and District Health )ffices "ill
follo" a transparent procedure on procurement in line "ith PP#A rules and
regulations:
9B7 ,fficient supply management system "ill &e developed to store and transport
medicines at provincial4 district and facility level:
9D7 *o ensure that drugs manufactured for pu&lic sector facilities do not ma/e their "ay
in the mar/et4 they "ill &e pac/aged separately:
987 inistry "ill develop a &aseline position to clearly articulate the Pa/istan specific
pu&lic health impact of the !orld *rade )rganization 6!*)7 agreements? and "ill
enhance capacity to ta/e advantage to override certain provisions of !*) in the
interest of ma/ing lo"5cost high quality drugs "hich are accessi&le to all:
<=
Draft National Health Policy 2009
Policy 1!2ective -: Strengthening ste"ardship functions in the sector to ensure service
provision4 equita&le financing and promoting accounta&ility
DH: Strengthening of health systems performance depends upon three vital functions4 i:e:
service provision4 financing and promoting accounta&ility: Health System "ill &e
strengthened through follo"ing policy actions>
Policy "ctions:

-%": Service provision !y p)!lic and private sector
97 inistry and Departments of Health "ill e.plore the option of esta&lishing Health
services accreditation authorityI mechanism to ensure implementation and monitoring
of essential service delivery pac/ages4 developing policy and legislation on pu&lic
private partnerships 6PPP74 regulating partnerships and addressing patient safety
issues:
<7 In close partnership "ith private sector professional &odies4 provincial governments
"ill esta&lish regulatory authorities: 1overnment "ill also focus on formulating
minimum standards of quality care and implementing quality assurance mechanism
for services &y the private sector:
B7 #ole of Health 0oundations "ill &e revie"ed and these foundations "ill &e
restructured "ith increased involvement of private sector: *he o&'ective "ould &e to
finance private health sector for provision of priority services in the rural areas:
D7 Private sector including -1)s "ill &e mainstreamed into the development process
and harnessing their potential to deliver services: *he government "ill further
promote the role of the private sector in the delivery of health services4 "ith attention
to quality and patient safety and safeguarding the interests of the poor and
marginalized:
87 !ays and means "ill &e e.plored to integrate the system of traditional medicine into
the formal health care delivery system4 ensuring patient safety and quality of care:
@7 Pu&lic sector service provision "ill &e improved &y supporting decentralization and
devolution of administrative and financial authorities at the local level along "ith
community oversight: Q
H7 Service delivery system "ill have appropriate chec/s and &alances "ith clear roles of
the three tiers of the government4 "ith federal and provincial governments focusing
more on ste"ardship functions of policy ma/ing4 strategic planning4 monitoring and
evaluation4 standards setting4 quality assurance4 regulations and financing:
G7 3n public sector, the number of ertiary level hospitals will not be
increased* rather focus will be on improvin" +uality of services by
developin" and implementin" protocols and standards of care for
"eneral care and specialities#
E7 1reater autonomy to the pu&lic sector hospitals "ill &e encouraged follo"ing detailed
planning4 changes in legislation and contracts and esta&lishing monitoring mechanism
and performance assessments:
9=7 *elemedicine "ill &e promoted in the country for transferring health /no"ledge and
s/ills from tertiary hospitals to secondary level hospitals: *his "ill also help in
esta&lishing lin/ages among international hospitals4 tertiary level hospitals and
districts for &etter provision of service delivery:
11) 3t is important to learn lessons from di6erent disasters durin"
last few years and establish a well@coordinated response and
<9
Draft National Health Policy 2009
disaster relief e6orts# 4inistry and Departments of 7ealth will ta0e
the initiative to build capacity of the health sector for disaster
mana"ement, devisin" an institutional arran"ement and
implementin" disaster mana"ement protocols* and plan at national,
provincial and district levels for an e6ective emer"ency response#
-%B: inancing
97 *he government "ill remove all types of user fees for services at primary health care
facilities and community level4 "ith safety nets for the poor see/ing care at referral
hospitals:
<7 Pu&lic sector health care financing "ill &e scaled up using predominantly ta.5&ased
revenues:
B7 Pu&lic sector financing "ill &e augmented &y more effective use of development aid
and accessing more financial support from glo&al initiatives4 &ilaterals and
multilaterals:
D7 *he government is committed to reduce out of poc/et e.penditures for health
especially &y the poorest: Social Health Insurance may &e an alternative &ut it needs
to prove itself as effective4 efficient and equita&le as ta.5&ased financing:
-%#: "cco)nta!ility and 4esponsiveness
97 Pu&lic health sector as a part of the government is ans"era&le to the parliament:
inistry of Health "ill regularly give &riefings to the Standing committees on health
in Senate and -ational Assem&ly and "ill see/ advice: Same sort of &riefings "ill &e
for the health committees of the provincial assem&lies: Pu&lic accounts committee
"ill revie" the audit reports of the pu&lic health e.penditures:
<7 inister of Health "ill give annual progress report to the Ca&inet in the month of
AugustI Septem&er of every year on the status of implementation of -ational Health
Policy:
B7 Provincial inisters of Health "ill also share annual progress report to the provincial
ca&inets the month of AugustI Septem&er of every year on the status of
implementation of provincial health sector strategic frame"or/s:
D7 At district level4 e.ecutive district officer 6Health7 "ill regularly &rief the district
government and assem&ly on the implementation of health schemes and programmes:
87 Annual progress reports "ill &e shared "ith the general population through media:
@7 inistry and Departments of Health "ill also &e responsi&le for regular performance
audits of service delivery and results disaggregated &y districts:
H7 Citizen community &oards 6CCBs7 "ill monitor the progress of health interventions at
the community level: ClientIpatient satisfaction surveys "ill &e conducted regularly
for selected health interventions:
G7 Hospitals &oards "ith mem&ers from elected representatives and technocrats "ill &e
formed to revie" progress of respective hospitals: PatientCs satisfaction surveys "ill
&e held regularly in selected hospitals:

<<
Draft National Health Policy 2009
Policy 1!2ective 3: Improving evidence &ased policy ma/ing and strategic planning in the
health sector:
DG: Pu&lic health sectorCs decision5ma/ing cycle comprises of policy analysis4 goal and
target setting4 resource allocation4 "or/ planning4 operational implementation and
performance assessment: *he overall purpose of the monitoring and evaluation system "ill &e
to provide continuous information and management support to decision5ma/ing processes at
each decision5ma/ing levels of the health system:
Policy "ctions:
97 -ational Health Information System "ill &e reformed: It "ill &ase on a strategic
frame"or/ and "ill consist of four pillars> i7 anagement Information Systems? ii7
Surveillance System? iii7 Health Household Surveys? and iv7 #esearch:
<7 *he &ase of anagement Information Systems "ill &e &roadened &y implementing
District Health Information System 6DHIS7 in all districts? e.panding it to hospitals
and private sector? and aligning it "ith other anagement Information Systems
6IS7 of national programmes: Analysis and use of information "ill &egin at local
level "ith feed&ac/ loop and also transmitting information up"ard at district4
provincial and federal level for decision ma/ing process:
B7 ,.isting piecemeal infectious surveillance system "ill &e integrated into a
comprehensive Disease surveillance system "ith &ac/ up support of diagnostics and
immediate response mechanism: Behavioral surveillance and vital registration "ill &e
lin/ed at a later stage: Plan of action has already &een developed4 "hich "ill &e
operationalised &y esta&lishing a system at district4 provincial and national level:
,pidemiologist "ill &e trained and deployed at all levels for investigative and
analytical "or/:
D7 Information "ill &e collected through national4 provincial and district level household
surveys to measure progress on health outcomes and processes: inistry and
Departments of Health "ill coordinate "ith 0ederal Bureau of Statistics and Planning
Commission to include relevant health indicators in national and provincial household
surveys:
87 Pa/istan edical #esearch Council 6P#C7 "ill draft a five year research strategy in
line "ith ne" national health policy: A similar research agenda "ill &e developed and
implemented at provincial levels: P#C "ill &e responsi&le to disseminate research
results4 ne" discoveries4 etc: to the Policy Units4 parliamentarians and end users of
the health care delivery system and the research mar/ets: P#C "ill regulate and
coordinate research activities of national and international institutions in the country:
P#C "ill also &e responsi&le to ensure availa&ility of financial4 technical and
technological resources for health research in the country: #esearch Culture "ill &e
developed through reformulated medical education curriculum for undergraduate and
postgraduate medical education:
@7 All four pillars of Health Information System "ill feed into Health Systems and
Policy Unit at federal level and Health Sector #eform Units for policy and strategic
frame"or/sC development4 implementation and monitoring: All policy and strategic
units "ill also &e responsi&le to conduct policy level research4 "hich "ill provide
evidence to inform policy and strategic decisions:
H7 All spending decisions "ill &e &ased on quantitative information a&out e.pected
outputs and outcomes of pu&lic sector interventions: *hrough implementation of
edium *erm Budgetary 0rame"or/s4 &udget allocations "ill &e lin/ed "ith policy
o&'ectives on one end and interventionIprogramme outputs on the other end:
<B
Draft National Health Policy 2009
099% 4es)lts and indicators of s)ccess
DE: *he /ey performance indicators to measure implementation progress against /ey
policy o&'ectives are summarized in Anne.ure I: *he inistry of Health "ill "or/ closely
"ith the Provincial Departments of Health and 0ederal Bureau of Statistic 60BS7 to ensure
collection of the data to tract trends and to disaggregate information &y gender and income
quintiles: inistry and Departments of Health "ill regularly monitor progress on "hat is
&eing achieved at different levels4 using clearly defined and measura&le output indicators for
each heath sector pro'ect:
8=: -ational Health Systems and Policy Unit esta&lished under the inistry of Health
and Health Sector #eform and onitoring 3 ,valuation units "ill &e esta&lishedI
strengthened to serve the strategic function of generating evidence4 measuring results4
dissemination and guiding the policy: *hese units "ill &e responsi&le to monitor progress on
results and report against indicators &y underta/ing regular health sector performance
assessments &y provinces and districts "hich "ill &e disseminated through oHCsI D)Hs
"e&site and via media: *hese assessments "ould &ecome the &asis for federal and provincial
dialogue and setting resource priority especially focusing on those districts "hich are
performing lo" in district ran/ing:
<D
Draft National Health Policy 2009
0999% Translating policy into action:

97 Pu&lic sector e.penditure on health "ill &e increased in line "ith 0iscal
#esponsi&ility Act <==8: At present4 pu&lic health e.penditures are =:@F of the 1DP:
In the first stage efforts "ill &e made to increase pu&lic sector health e.penditures to
=:G8F of the 1DP &y <=99I9< and later on a&ove 9:8F of the 1DP &y <=98:
<7 0ederal4 ProvincialI Area and District governments re5affirm achieving health
related D1s: *o transform this commitment4 federal and provincialIarea
governments agree to develop costed health sector strategic plans "ith province
specific monitoring targets for outcomes and outputs4 to achieve D1s and policy
o&'ectives of the -ational Health Policy <==E: Strategic frame"or/s "ill further
prioritize policy actions considering availa&le resources: After announcement of
-ational Health Policy <==E4 the strategic frame"or/s "ill &e finalized and approved
"ithin a time frame of si. months:
B7 *he policy and strategic frame"or/s "ill &e disseminated "idely to policy
ma/ers4 legislators4 local leaders4 economic and finance e.perts4 media4 development
partners and general pu&lic4 &riefing them the important role of health in reducing
poverty and producing high quality human capital:
D7 -ational Health Systems and Policy Unit at federal level and Health Sector
#eform UnitsIonitoring and ,valuation units at provincial level "ill regularly
revie" and monitor the progress on -ational Health Policy <==E and Strategic
0rame"or/s: *hese units "ill also generate evidence and disseminate that to highlight
progress or issues:
87 Detailed roles and responsi&ilities at different levels of the government "ill
&e agreed as part of the strategic plans:
@7 All development partners "ill &e as/ed to align their investments in health
sector in line "ith strategic plans: onitoring mechanisms "ill &e harmonized so that
results are accepta&le to all: Both the government and development partners "ill &e
mutually accounta&le: ,ach year4 inistry of Health "ill organize t"o meetings of
Health Development Partners 0orum to revie" the reform process and to set agenda
for the future:
H7 -ational Health Policy5<==E "ill &e aligned "ith other strategic documents
i:e: 2ision <=B=4 *D04 P#SPs4 *B0 and provincial strategic plans etc:
0999% "nne7)re
 I> )utcome and )utput targets + &aseline4 &enchmar/s and targets
 II> 0unctions and #esponsi&ilities
 III> ,ssential Service Delivery Pac/age
<8
Draft National Health Policy 2009
"nne7)re 8 9
Health Sector Indicators 6Baseline4 Benchmar/s and *argets7 for -ational Health Policy <==E
Policy
1!2ective>s
9ndicators
Baseline
2003805
Benchmarks and Targets
20098$0 20$08$$ 20$$8$2 20$28$* 20$*8$+ 20$+8$-
H<"?TH 1@T#1M<S
94<4B4D484@ R8 mortality rate 6per 9=== l&7 9+ HG HB @G @8 @= 88
94<4B4D484@ Infant mortality rate 6per 9=== l&7 56 @@ @< 8G 88 DG DB
94<4B4D484@
aternal mortality ratio 6per 9==4=== l&7 253 <D= <<= <== 9H8 9@8 98=
94<4B4D484@ *otal fertility rate +%$ B:H B:@ B:@ B:8 B:8 B:8

#10<4"G<
94<4B
F of children 69<5<B months7 fully immunized
6Disagregation &y gender and income7 53 A+5B HG G= G< GD GD G8
94B Antenatal care at health facility -* @8 @G H9 H8 HG G9
94<4B *etanus *o.oid coverage -3 8G 8E @= @< @B @D
94B48 F of &irths attended &y SBAs *3 D@ 8< 8@ @= @8 H<
94B48 F of institutional deliveries *2 D= DD DG 8< 8@ @=
94B
Contraceptive prevalence rate 5 F 6Disagregation
&y gender and income7 *0 BB BD B8 B@ B@ BH
< *B 5 Case detection rate 6SSS7 5 F -$ HD HH HE G= GB GD
<4B *B 5 *reatment success rate 5 F 65 GH GG GG:8 GE E= E9
<
F of families sleeping under insecticide treated
nets in high ris/ areas 5 8 H 99 98 <= <G
< Prevalence of Hepatitis B3C 5 @ 8

H<"?TH SCST<M 1@TP@TS
94<4B48
Health facilities utilization rate 6curative7 5
Patients per day per facility ** B@

BH BG D= D= D9
94<4B48
Patient satisfaction5F population utilizing pu&lic
hosp 3 facilities 20 <B

<8 <H B= B< BB

<@
Draft National Health Policy 2009
H<"?TH SCST<M 9&P@TS
@ in: govt: e.penditure on health as F of 1DP 0%-5 =:H< =:HG =:G8 t&c t&c t&c
@
*otal e.penditure on health per capita 6#s: Per
person per yr7 *0-
D
G9
8
DG
@
9H t&c t&c t&c
D Doctors per 9=== population 0%5- =:HG =:G= =:G9 =:GB =:G8 =:GH
D
-urses per 9=== population 0%*+ =:BG =:D= =:D< =:DD =:D@ =:DE
D $H2s per 9=== population 0%0+5 =:=8D =:=8@ =:=8E =:=@< =:=@8 =:=@G
94D $H!s per 9=== population 0%-+ =:@9 =:@@ =:@@ =:@G =:@G =:@H
94B Hospital &eds per 9=== population 0%3- =:@D =:@D =:@D =:@D =:@D =:@D
D
F of Health facilities "ith stoc/ out of essential 8
medicines 52 @D @9 8B 8= D8 D=

49S, "#T14S
<48 IDUs al"ays using ne" syringes +$ 8B 8@ 8E @B @G H9
94<4B alnutrition 6"eight for age7 5 F *3 B8 BD BB BB B< B=
9 ,.clusive &reast feeding 2*%$ <D <H B9 B@ D< 8=

<H
Draft National Health Policy 2009
"nne7)re 8 99
Pakistan Health System: #ore )nctions and 4esponsi!ilities
#ore )nction ederal Provincial .istrict
S<409#< .<?90<4C:
Delivery of services T TT TTT
Preventive and primary health care
programmes
T TT TTT
Health education and promotion T TT TTT
Advocacy4 liaison and community
mo&ilization
TT TT TTT
H@M"& 4<S1@4#<:
Health professions regulations TTT TT
edical colleges4 nursing and
paramedical schools
T TTT T
Human resource development and
training
T TT TTT
Integrated supportive supervision T TT TTT
Human resource management TT TT TTT
9&14M"T91&:
Data collection and use T TT TTT
Surveillance and diagnostics TTT TTT TTT
Health #esearch TTT TTT TT
Surveys TTT TTT T
M<.9#"? P41.@#TS:
#egulation TTT TT
Procurement TTT TTT TTT
Supply management TTT TTT TTT
9&"&#9&G:
Health financing TTT TTT T
0inancial anagement TTT TTT TTT
?<".<4SH9P "&. G10<4&"&#<:
Policy formulation and strategy
development and revie"
TTT TTT
$egislation TTT TTT
Business planning 6includes resource
pro'ections 3 allocation7
TTT TTT TTT
icro planning T TT TTT
Inter sectoral coordination TTT TTT TTT
Inter provincial coordination TTT
Inter district coordination TTT
Intra district coordination TTT
1eneral management and administration TTT TTT TTT
Service Delivery Standards TT TTT
Pu&lic private partnership 6PPP7
regulation
TTT TTT
Pu&lic private partnership contracts TT TTT TTT
,nvironmental health TT TT TT
Disasters and emergencies TTT TTT TT
anagement of donor support TTT TT
<G
Draft National Health Policy 2009
"nne7)re 8 999
<ssential Service .elivery Package
*he ,ssential Service Delivery Pac/age 6,SDP7 is not only a set of physical infrastructure4
staff4 equipment and supplies &ut is also a series of specific health activities and standards of
care: ,ach provincialI area government "ill further define ,SDP contents considering local
needs and su& classification of health facilities: ,ach provincialIarea government "ill
priorities the elements of ,SDP to focus on in the initial phase: ,mphasis "ould &e to
implement ,SDP in socio5economically poor districts: *hese priorities "ould &e a part of
Provincial health sector strategic frame"or/s:
*he pac/age of services may comprises of t"o parts? the first part is the minimum 6core7
component of the programme that needs to &e in place to reduce mor&idity and mortality and
is recommended for adoption on an as &asis? the second component comprises of proposed
interventions "hich can &e added as per local requirements and priorities:
a% BH@ ?evel Package:
*he proposed pac/age of the BHU $evel health facility envisages a facility4 "hich has a
catchmentCs area population of around 84===59<4=== and need not necessarily &e staffed
&y a full time medical doctor: BHU level health facility comprises not only the physical
facility &ut also includes the outreach and community &ased health "or/ers4 as the staff of
the BHU level health facility is also responsi&le for monitoring and ensuring the outputs
for the population &ase of the 0$C0:
*he minimum service pac/age required at this level of care is proposed as follo"s>
C)#, Pac/age>
• Curative care for common illnesses 6including first aid and provision of
essential medicines7
• ,PI 6plus7 services
• Integrated anagement of -eonatal and Childhood Illness
• -utrition adviceI services
• Prenatal and postnatal care
• Birth preparedness counselling
• -e"&orn care
• *reatment of diseases li/e malaria4 tu&erculosis4 hypertension4 dia&etes
and s/ins infection etc:
• 0amily Planning counselling and services including Intra uterine device
6IUD7 insertion and removal services
• Information and ,ducation for ,mpo"erment and Change 60amily
mem&ers4 pregnant "omen4 parents4 traditional care providers etc7
• *raining and management support for community &ased lady health
"or/ers
AdditionalI )ptional Services>
• <DIH Basic ,m)-C services only if transportation and referral to higher level is
availa&le and can &e ensured
• )&stetrical care
• $a&oratory support for antenatal care
• Promotion of Iodized salt
• S*I including HI2IAIDS counselling and referral
<E
Draft National Health Policy 2009
• Psychological reha&ilitation
• Physical reha&ilitation
!% 4H# ?evel Package:
*his is envisaged as a health facility4 "hich is open <DIH and staffed &y medical doctors:
*he envisaged catchmentCs population of this health facility is around 9<4===5D=4===:
*his facility "ill also provide management support to the attached BHUs:
*he minimum service pac/age required at this level of care is proposed as follo"s>
C)#, Pac/age>
• Curative care for common illnesses 6including first aid and provision of
essential medicines7
• ,PI 6plus7 services
• Integrated anagement of -eonatal and Childhood Illness
• -utrition adviceI services
• Prenatal and postnatal care
• Birth preparedness counselling?
• <DIH Basic ,m)-C services including handling normal deliveries and
availa&ility of interventions for minor complications of deliveryI post a&ortion
care
• -e"&orn care including resuscitation
• Comprehensive 0amily Planning counselling and services 6including referral
services for surgical contraceptive services7
• S*I including HI2IAIDS counselling and services
• <DIH *ransportation 6Am&ulance7 services
• Diagnostic and *reatment of diseases li/e malaria4 tu&erculosis4 hypertension4
dia&etes and s/ins infection etc:
• Diagnostic services> la& and radiology
• Dental care services
• Information and ,ducation for ,mpo"erment and Change 60amily mem&ers4
pregnant "omen4 parents4 traditional care providers etc7
• *raining and management support for community &ased lady health "or/ers
AdditionalI )ptional Services>
• Advanced la&oratory services
• Blood &an/4 Blood screening and transfusion services
• Promotion of Iodized salt
• inor surgical operations
• ental health services I Psychological reha&ilitation
• Physical reha&ilitation
• *raining of mid"ives
c% 4eferral Hospital ?evel Package:
*his is envisaged as a hospital4 "hich is open <DIH and staffed &y medical doctors and
specialists: *he envisaged catchmentCs population of *H( hospital is around 9==4=== to
B==4===4 "hereas for DH( hospital4 the catchmentCs population "ill &e around B==4===
or a&ove:
In addition to Core and additional services offered at #HC level facility4 the follo"ing
services "ill &e implemented>
B=
Draft National Health Policy 2009
• edical4 surgical4 paediatric and gynaecological and anaesthesia 5 specialized
services in all *H(H: In addition to specialized services essential for all
*H(H4 at least specialized services for ,-*4 ophthalmologic and cardiology
"ould &e ensured in all DH(H:
• Diagnostic services including la& 3 radiology
• Comprehensive ,m)C services including post5a&ortion care
• -e"&orn care including incu&ator care
• *herapeutic feeding centres
• Comprehensive family planning services including surgical sterilization
services for men and "omen
• *raining of health care providers and paramedics
d% Tertiary #are ?evel Package:
In addition to Core and additional services offered at #eferral level hospital4 the follo"ing
services "ill &e implemented>
Support 3 delivery of all services offered at DH( and *H( hospital level
All types of specialties
All diagnostic services
*raining of medics and paramedics
Physical reha&ilitation services including prosthesis
e% #omm)nity level 61rass root level through out5reach services7>
In addition to "hat has &een proposed &y the $H!sC Programme4 the follo"ing additional
services may also &e provided through $H!s>
• ,PI services
• Psychosocial support
• Provision of clean delivery /its4 -utrition supplementation and 0irst aid 6plus7
etc
*he pac/age of services for community mid"ives "ill &e as prescri&ed &y the -ursing
council
B9
Draft National Health Policy 2009
4<<4<&#<S
9>
B<

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