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    C HAPTER 11  Health and Nutrition   Investment in health has a long term beneficial effect. It improves health outcomes, reduces poverty and contributes in promoting economic growth. At the backdrop of this perspective, the federal as well as provincial governments are spending sufficient amount on health and education to bring the social sector into main stream of development. The federal government recently initiated several programmes to meet the needs of health care and keep the people healthy, such as introduction of national health insurance scheme, notification of drug pricing policy 2015 and a continued strong focus on polio eradication across the country. The passage of 18 th  Amendment has made the provinces financially more autonomous and more powerful to decide their own health system and health policies. Provincial governments of Punjab, Sindh and KPK have devised long term health sector strategies (2012-20) to improve health outcomes and enhance the coverage of essential health services. In Feb 2015, the KPK government established Health Care Commission (HCC) with the mandate to regulate the private health sector as well as to ensure the provision of quality health care services in the public sector through the process of performance audit and evaluation of hospital services. The Government of Sindh has enacted the Sindh Health Care Commission Act 2013. The act aims at provision of effective delivery of health services to whole province. The Punjab Health Care Commission Act 2010 is already in place aimed at improving performance, effectiveness and provision of quality health care services. With regard to nutrition activities, all the four provinces have promulgated laws on breast feeding and allied issues. During FY2016 it will be carrying out following up activities for the implementation of the laws on breast feeding in all the provinces and also at federal level. The objectives of all these activities are meant to ensure better health outcomes. Health and SDGs The post MDGs Development Agenda “Sustainable Development Goals” (SDGs) has came into effect on 1 st  January, 2016. The Government of Pakistan has adopted the SDGs and its goals have been incorporated into the Vision 2025.The SDGs attempt to address all dimensions of sustainable development-economic, social and environmental and focuses on health, education, energy, water, poverty, food and climate for promoting well being of all to be attained by 2030. Almost all the SDGs are directly or indirectly will contribute to health. Goal 3 of the SDGs i.e. to ensure healthy lives and promote well being for all at all levels is now being followed for achievement of the desired targets regarding communicable and non-communicable diseases. Health Expenditure: Public health spending provides an important insight on a country’s health progress. Various foundations, societies, individual philanthropists, community affiliation, Islamic organizations and individual contribute to finance health in Pakistan. Using data from World Bank, Pakistan spends US$ 37 per capita on health which is lower than the WHO’s prescribed level of per capita US$ 44, a minimum spending package required for essential health services. The total public health expenditure as percentage of GDP has increased to 0.45 percent in FY2016. The current level of expenditure amounting Rs.133.9 billion or 0.45 percent of GDP shows an increase of 17.2 percent over corresponding period of last year. The federal and provincial share in total public spending on health shows that Balochistan and KPK are spending the least (see Fig-11.2). The  Pakistan Economic Survey 201  190 major share of spending on Table 11.1: Health & Nutrition Expe Fiscal Years Public Sect Total Health Expenditures 2000-01 24. 2001-02 25. 2002-03 28. 2003-04 32. 2004-05 38. 2005-06 40. 2006-07 50. 2007-08 59. 2008-09 73. 2009-10 78. 2010-11 42. 2011-12 55. 2012-13 125. 2013-14 173. 2014-15 199. 2014-15* 114.2015-16* 133.*Expenditure figure for the respective y Source: Finance Division (PF Wing) 2005-062006-072Development 16.0 20.0 Current 24.0 30.0 Total 40 50 020406080100120140160180200    P  a   k   R  s .   (   b   i   l   l   i  o  n   ) Fig-11.1: Total Public Se 2012-13Federal11.4Punjab47.8Sindh43.5KPK12.8Balochistan10.4010203040506070    (   R  s .   B   i   l   l   i  o  n   ) Fig-11.2: Share in Total Public 5-16 health has been observed in Punjab follo   ditures (2000-01 to 2015-16) or Expenditure (Federal and Provincial) Per C Development Expenditure Current Expenditure 28 5.94 18.34 41 6.69 18.72 81 6.61 22.21 81 8.50 24.31 00 11.00 27.00 00 16.00 24.00 00 20.00 30.00 90 27.23 32.67 80 32.70 41.10 86 37.86 41.00 09 18.71 23.38 12 26.25 28.87 96 33.47 92.49 42 58.74 114.68 32 69.13 130.19 22 31.93 82.29 93 39.94 94.00 ears are for the period (July-March) 007-082008-092009-102010-112011-122012-132013-142027.2 32.7 37.9 18.7 26.3 33.5 58.7 32.7 41.1 41.0 23.4 28.9 92.5 114.7 1 60 74 79 42 55 126 173 tor Expenditure on Health 2013-142014-152014-15(Jul-Mar)34.736.222.455.167.736.546.651.229.624.530.816.912.513.58.9  Sector Health Expenditure  ed by Sindh. (Rs. billion) entage ange Health Expenditure as % of GDP 9.98 0.58 4.63 0.57 13.42 0.59 13.85 0.58 15.84 0.58 5.26 0.49 25.00 0.54 19.80 0.56 23.21 0.56 6.86 0.53 -46.63 0.23 30.96 0.27 128.51 0.56 37.68 0.69 14.94 0.73 11.62 0.42 17.26 0.45 14-152014-15 (Jul-Mar)2015-16 (Jul-Mar)9.1 31.9 39.9 30.2 82.3 94.0 199 114.2 133.9 2015-16(Jul-Mar)15.359.735.014.59.4  Health and Nutrition 191 Health care System Good services delivery is an important element of any health system. In Pakistan, public and private health care systems run in parallel. The public sector until recently led by the Ministry of Health has devolved to the provinces. The administrative and fiscal space of provinces have increased mani-fold with simultaneous increase in their responsibilities but is still deficient in health workforce and facilities relative to population. The private sector is playing a vital role in the health care services delivery in Pakistan. Majority of private hospitals, clinics and health related facilities are in the urban areas and are well equipped with latest diagnostic facilities. Private health care option is in more demand than the public health care. Health Facilities Health care provision in Pakistan is the responsibility of the government. The health care system has expanded gradually with large network of health facilities, workforce and services across the country. Currently the public health care system comprises of 1167 hospitals, 5695 dispensaries, 5464 basic health units, 675 rural health centers, 733 mother and child health centers and allied medical professionals i.e. doctors, nurses, midwives and pharmacists. As of FY2016, there are 184711 doctors, 16652 dentists and availability of 118869 hospital beds in the country. The ratio of one doctor per 1038 person, one hospital beds for 1613 person and one dentist for 11513 persons shows a clear inadequacies particularly in case of dentists and hospital beds. Table 11.2: Healthcare Facilities   Health Manpower 2011-12 2012-13 2013-14 2014-15 2015-16 Registered Doctors 152,368 160,880 167,759 175,223 184,711 Registered Dentists 11,649 12,692 13,716 15,106 16,652 Registered Nurses 77,683 82,119 86,183 90,276 94,766 Population per Doctor 1,162 1,123 1,099 1,073 1,038 Population per Dentist 15,203 14,238 13,441 12,447 11,513 Population per Bed 1,647 1,616 1,557 1,591 1,613 Source: Pakistan Bureau of Statistics Health Programmes To improve health status of the people and reduce burden of disease a series of programs and projects are on track. Although vertical programmes in health sector have been devolved to the provinces. In pursuance to decision of Counsel of Common Interest (CCI) and upon request of the provinces, funding for these vertical programmes during the currency of 7 th  National Finance Commission (NFC) award has been catered for the federal government. The federal government has launched “Prime Minister’s National Health Insurance Program” to improve the health status of the population in the country by ensuring access to quality health care especially enhancing coverage and access to secondary and priority treatments of the poor and vulnerable population with the objectives of reducing Out-of-pocket catastrophic health expenditures by insured families for effective care. The scheme would cover secondary healthcare including daycare & maternity services. Priority treatment list consists of cardio vascular diseases, diabetes, burns, road traffic accidents, renal diseases & dialysis, TB, hepatitis, treatment of HIV, chronic liver diseases, chemotherapy & surgical oncology. The program for Civil Registration and Vital Statistics (CRVS): Ministry of Planning, Development and Reforms is leading and coordinating the process of acceleration and enhancement of CRVS in Pakistan. In this regard, the aim is to develop a strategic plan through stakeholder’s consensus for enhancement / improvement in a sustained and acceptable manner. After conducting situation analysis in the form of Rapid and Comprehensive assessments of CRVS in Pakistan, and the fact the CRVS is a multi-stakeholders subject, an institutional set up in the form of a National Steering and Coordination Committee has been set up in Planning Commission / Ministry of Planning, Development and Reforms under the  Pakistan Economic Survey 2015-16 192 Chair of Minister for Planning, Development and Reforms. Provincial and Area Governments have set up their respective Implementation and Coordination Committees. The overall purpose is to provide a steering and coordination role at national level and to formulate a national strategic plan for acceleration and enhancement of CRVS in Pakistan. Two (02) meetings of the committee have been held so far and six (06) thematic areas identified which will become the objectives of the National CRVS Strategic Plan. For each thematic area, six (06) Technical Sub-Groups have been formulated with representation of all the stakeholders including the provincial and area governments and technical experts. It is expected that by the end of year 2016, the plan would be finalized. UNICEF and World Bank have shown their interest to sponsor, both technically and financially the development and implementation of National Strategic Plan and Provincial Action Plans. Following programs and projects have been funded through the PSDP during FY2016 and implemented by the provincial and areas governments. An amount of Rs: 23.2 billion has been provided in federal PSDP 2016.    Programme for Family Planning and Primary Health Care (LHWs Program) LHWs services have visible impact on the health status of women and children in particular through improved hygiene, birth spacing, iron supplementation, greater immunization coverage and through Ante-natal and post-natal coverage of the pregnant women. The program has recruited more than 100,000 Lady Health Workers (LHWs). The total population covered under this program spread over 60 percent in Baluchistan and more than 80 percent in Punjab. A new PC-I of provincial and area governments are under the process of approval in which salary packages of the staff of the program is to be increased and their services are to be regularized in compliance with the orders of the Honorable Supreme Court of Pakistan. These proactive steps will definitely lead towards greater commitment and better health service delivery at the door steps of the vulnerable people. However, issues of governance and monitoring still needs attention at the district and sub districts levels.    Expanded Program of Immunization (EPI): EPI program provides immunization against the seven vaccine-preventable diseases i.e. childhood tuberculosis, poliomyelitis, diphtheria, pertussis, neonatal tetanus, measles and hepatitis B to children under one year of age. New vaccines like Pentavalent vaccine have been introduced with the help of United Nations Children Fund’s (UNICEF). During the year 2015-16, 7 million children of 0-11 months and 6.5 million pregnant women were immunized against 7 deadly diseases and tetanus toxoide vaccine, respectively. Though after devolution this has become largely the responsibility of the provincial/ area governments but Federal EPI Cell currently took the responsibility of the vaccines procurement, coordination and technical guidance, whereas, provincial EPI cells are largely responsible for implementation of the program. World Bank along with other development partners such as World Health Organization (WHO) and Japanese International Cooperation Agency (JICA) has largely contributed towards smooth implementation of the program. Still the issues of routine immunization in out reached areas of Federally Administered Tribal Areas (FATA) and Baluchistan needs attention.    Malaria Control Program: Malaria is the 2 nd  most prevalent communicable disease in the country. It has been the major cause of morbidity in Pakistan. More than 90 percent of disease burden in the country is shared by 56 highly endemic districts, mostly located in Baluchistan (17 out of 32 districts), FATA (7 agencies), Sindh (12 districts) and Khyber Pakhtunkhwa (12 districts). Most of the reported cases from these districts are due to falciparum malaria which is the most dangerous form of malaria. FATA is the second highest malaria affected belt of the country which accounts for 12-15 percent of the total case load of the country. National strategy for Malaria Control is based on the following six key Result Based Monitoring (RBM) elements.
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