Poor Performance of Health and Population Welfare Programmes in Sindh: Case Studies in Governance Failure

Over the past few years, the issue of what is meant by “good governance” has generated increasing attention and debate both at the national and international level [Streeten (1997)]. The role of state and how that role is to be exercised is appearing high on the agenda of politicians, policy-makers and academicians in the developing world. Governance has been defined by the World Bank as “the manner in which power is exercised in the management of the country’s economic and social resources” [World Bank (1994)]. The somewhat narrow scope of this definition has been broadened in recent years to “the sum of the many ways individuals and institutions, public and private, manage their common affairs” [Commission on Global Governance (995)] The Human Development Report [UNDP (1999)] goes beyond these definitions and gives a much more radical notion of good governance, underpinning the importance of peoples’ participation in shaping their own governance and development. This type of governance has been labeled as “humane governance”. A review of existing literature thus shows that governance has been interpreted to have different elements such as management of economic and social resources for development, formulation and implementation of policies, discharging of functions, accommodation of diverse interests towards cooperative action and above all, accountability to people and ownership by the people of the governance process. In view of the above, one may ask what constitutes good governance for the health sector? Management of resources pertains to the concept of efficiency, a term appearing with increasing frequency in global literature on health care reforms; policy formulation and discharging of functions allude to the objective of effectiveness which itself has a wide scope encompassing relevance, quality and availability of health care; while “humane governance” brings in the notion of community participation and accountability with regards to decision-making and delivery of health care.

BUREAUCRATS AS PURCHASERS OF HEALTH SERVICES: LIMITATIONS OF THE PUBLIC SECTOR FOR CONTRACTING

Contracting out of health services increasingly involves a new role for governments as purchasers of services. To date, emphasis has been on contractual outcomes and the contracting process, which may benefit from improvements in developing countries, has been understudied. This article uses evidence from wide scale NGO contracting in Pakistan and examines the performance of government purchasers in managing the contracting process; draws comparisons with NGO managed contracting; and identifies purchaser skills needed for contracting NGOs. We found that the contracting process is complex and government purchasers struggled to manage the contracting process despite the provision of well-designed contracts and guidelines. Weaknesses were seen in three areas: (i) poor capacity for managing tendering; (ii) weak public sector governance resulting in slow processes, low interest and rent seeking pressures; and (iii) mistrust between government and the NGO sector. In comparison parallel contracting ventures managed by large NGOs generally resulted in faster implementation, closer contractual relationships, drew wider participation of NGOs and often provided technical support. Our findings do not dilute the importance of government in contracting but front the case for an independent purchasing agency, for example an experienced NGO, to manage public sector contracts for community based services with the government role instead being one f larger oversight. © 2011 John Wiley & Sons, Ltd.

A SINGLE-BLIND, PLACEBO-CONTROLLED CLINICAL TRIAL OF LOCAL APPLICATION OF KOHL-CHIKNI DAWA-A UNANI COMPOUND FORMULATION IN THE PATIENTS WITH CORNEAL OPACITY

Objective: The present clinical trial was undertaken to evaluate the safety, preventive/curative efficacy of the local application of Kohl-Chikni Dawa (KCD) in patients with corneal opacity (CO), to provide an economic, safe, and effective alternative treatment for it. Methods: The present prospective single-blind, placebo-controlled trial was undertaken at Majeedia Hospital, Hamdard University, New Delhi. Ninety-two diagnosed patients of CO were randomly allocated to three groups for local application of KCD/placebo two sticks BID. Results: Forty patients completed the 6-month duration of the study. KCD was found effective in the general amelioration of the signs and symptoms of CO. There was a statistically significant reduction in the CO score and improvement in vision on the reading of the Snellen chart in the test drug group in comparison to the placebo group in Grade-I (Nebular type) CO (p>0.05). Conclusion: KCD was found very much effective to reduce the CO score, with clinical improvement of vision in the nebular type of CO. The dose of KCD in two sticks BID was found safe and tolerable with no side effects. A multicentric trial of the test drug on larger sample size for a longer duration is required to establish the efficacy of the formulation on CO

Access to essential medicines: in Pakistan identifying policy research and concerns

The fundamental importance of ensuring access to medicines, particularly for the poor, is reflected in MDG 8 however remains poor in many low and middle income countries (LMICs). Country specific evidence on access to medicines is weak in LMICs and research has rarely been from an integrated health systems perspective. This study used an evidence based approach to identify key priority concerns and emerging research questions related to access to medicines in Pakistan. WHO’s Access to Medicine Framework was used as the conceptual basis for data collection on rational usage, affordability, financing and health systems. Methods involved a systematic desk review, in-depth stakeholder interviews and a consensus building Roundtable exercise. In Pakistan there has been considerable work in terms of medicines related policy acts and operative guidelines. However considerable gaps exist between policy and practice and between medicine policies and health systems strategies. Average number of medications prescribed is higher than other LMICs and prescription practices frequently do not follow standard recommended therapies from specialists down to general practitioners. There is a widely entrenched private informal sector and shadow pharmacies which remains largely unregulated. Spending on drugs is mainly borne by households, accounts for 63% of total spending on drugs in Pakistan as compared to only 18% in OECD countries and can lead to catastrophic household expenditure. Medicine therapy for chronic care is particularly unaffordable even with use of low cost generics. Within the public sector, availability of essential generics is extremely low at 3.3% as compared to 29-54% in LMICs. Public sector spending on drugs is far below the minimum $2 per capita indicated for LMICs and existing spending faces issues of questionable adherence to EDL, low quality drugs and outdated logistics management systems. Contracting out the management of BHUs has resulted in better medicine availability. There is serious shortage of trained manpower pharmacists across private and public sector with 0.9 pharmacist / 100000 population in Pakistan far below recommended ratio of 1 pharmacist per 2000 population. Drug regulation also requires with registration of excessive number of drugs, wide quality variation in quality and pricing, and frequent instances of spurious drugs and black marketing. Chronic shortage of low prices essential medicines is a long standing issue linked to disincentive to production due to low pricing and flat price control. The above policy concerns raise need for research in key areas. First, there is need for surveys on continuous surveillance of policy impact on availability, price and affordability of medicines; mapping of private informal sector and shadow pharmacies; and consumer health seeking preferences. Second, collation is required of best practice lessons on registration, pricing, market vigilance and enhancement of rational drug use. Third, operation research pilots in key areas such as alternative health financing mechanisms involving commodity voucher, GP contracting, pre-payment schemes, equity funds for increasing drug availability and affordability; scientific improvement of logistics management system in public sector; and introducing community participation in accountability mechanisms. Pharmaceutical policy and research needs to be centrally placed within larger health systems related initiatives. It needs to be accompanied by sustained dialogue and interaction between multiple stakeholders including private sector. Adequate steps also need to be taken to ensure a continuous culture of research feeding into evidence based policie

NPO performance in reproductive health sector of low and middle income countries: what is the influence of the wider policy context

Non-ProfitOrganizations (NPOs) are increasingly being promoted as preferred providers toreplace weak government services in Low and Middle Income Countries (LMIC) butresults on ground show mixed performance. The variation in national policycontexts is one explanation for uneven NPO performance but has beenunder-explored in reproductive health literature. This paper collates gray andpublished literature providing an overview of how policy context impacts on NPOperformance in reproductive health. Socio-political context, state policies anddonor dependency indirectly influence NPO working by shaping operational space,autonomy, networking and mandate. These influences need to be recognized andmodified so as to enable NPOs to better achieve their attributedcharacteristics of client responsive and quality services aimed at marginalizedpopulations. Policy measures are needed to build better policy space and regulatoryframeworks for NPOs, state-NPO collaboration forums, and greater reliance oninternal funding

Action on Under-Nutrition in Pakistan: Opportunities and Barriers

Undernutrition rates in Pakistan have remained unchanged for over half a century. Success in tackling under-nutrition relies on cross-sectoral action across health, food, agriculture, poverty, water and sanitation. A recent positive momentum has involved loose inter-sector coalitions in the provinces supported by international development partners. However, weak understanding of nutrition, low ownership, minimal allocations, siloed working of sectors and lack of effective homegrown coalitions constrain meaningful action. Pakistan requires political championing by the executive leadership, central convening structures in the provinces and common policy and monitoring frameworks.DFI

Exploring willingness to pay for health insurance and preferences for a benefits package from the perspective of women from low-income households of Karachi, Pakistan

Background: Achieving universal health coverage (UHC) and reduction in out of pocket (OOP) expenditures on health, is a critical target of the Sustainable Development Goals (SDG). In low-middle income countries, micro-health insurance (MHI) schemes have emerged as a useful financing tool for laying grounds for Universal Health Coverage. The aim of this study was to provide evidence for designing a feasible health insurance scheme targeted at urban poor, by exploring preferences for an insurance benefits package and co-payments among women from low-income households in Karachi, Pakistan.Methods: This was a descriptive cross-sectional study, conducted using household surveys between July-August 2015. A total of 167 female beneficiaries of Benazir Income Support Programme (BISP), a large-scale cash transfer scheme targeted at low-income households, were recruited in Karachi through a mix of convenience and snowball sampling. Hypothetical insurance benefits packages for a prospective health insurance scheme were formulated to capture respondents\u27 preferences for health insurance benefits package and co-payments. All data was analyzed using Stata (version 13).Results: Respondents reporting expenditure on OPD and hospitalization in the last 2 weeks were 93.4 and 11.9% respectively. The highest median expenditure was incurred on medicines. Out of the proposed benefits package, a majority (53%) of the study participants opted for the comprehensive benefits package that provided coverage for emergency care, hospitalization, OPD consultation, diagnostic tests and transportation. For the co-payment plan, 38.9% participants preferred no co-payments that is 100% insurance coverage of medicines followed by hospitalization (25.9%). Nearly half of the respondents (49.4%) chose outpatient consultation for 50% co-payment. A majority of the participants (65.3%) agreed to 100% co-payment for the transportation cost.Conclusion: Health insurance schemes can be introduced in urban areas, against collection of micro-payments, to prevent low-income households from facing financial catastrophe. A comprehensive benefits package covering emergency care, hospitalization, OPD consultation, diagnostic tests and transportation, is the most preferred among low-income beneficiaries

Rational prescription & use: a snapshot of the evidence from Pakistan and emerging concerns

Introduction: Irrational drug use remains globally common and there is a lack of country level synthesis for strategizing policy actions in Pakistan. Methodology: We conducted a scoping review of available peer reviewed and grey literature on prescribing patterns and drug dispensing in Pakistan to identify emerging concerns. Results: There is excessive drug use in Pakistan compared to the average for LMICs with inappropriate prescribing, high use of injections and antibiotics, choice of more expensive drugs, inadequate dispensing and weak community pharmacy. Policy concerns include excessive drug registration, poor enforcement of essential drug lists and standard management protocols, open access of industry to health providers, and lack of private sector regulation. Conclusion and Policy Recommendations: Review of evidence demonstrates deviance from rational use in the areas of medicine prescription, dispensing and self-medication, and low impact of existing policy measures. Quality of research needs to be improved focusing on standardized national surveys, consumer related formative research, and interventional research. Rational drug use is a neglected area in Pakistan requiring policy measures at multiple levels of health system and continued and simultaneous investment in standardized researc

Poor performance of health and population welfare programmes in Sindh: case studies in governance failure

Over the past few years, the issue of what is meant by “good governance” has generated increasing attention and debate both at the national and international level [Streeten (1997)]. The role of state and how that role is to be exercised is appearing high on the agenda of politicians, policy-makers and academicians in the developing world. Governance has been defined by the World Bank as “the manner in which power is exercised in the management of the country’s economic and social resources” [World Bank (1994)]. The somewhat narrow scope of this definition has been broadened in recent years to “the sum of the many ways individuals and institutions, public and private, manage their common affairs” [Commission on Global Governance (995)] The Human Development Report [UNDP (1999)] goes beyond these definitions and gives a much more radical notion of good governance, underpinning the importance of peoples’ participation in shaping their own governance and development. This type of governance has been labeled as “humane governance”. A review of existing literature thus shows that governance has been interpreted to have different elements such as management of economic and social resources for development, formulation and implementation of policies, discharging of functions, accommodation of diverse interests towards cooperative action and above all, accountability to people and ownership by the people of the governance process. In view of the above, one may ask what constitutes good governance for the health sector? Management of resources pertains to the concept of efficiency, a term appearing with increasing frequency in global literature on health care reforms; policy formulation and discharging of functions allude to the objective of effectiveness which itself has a wide scope encompassing relevance, quality and availability of health care; while “humane governance” brings in the notion of community participation and accountability with regards to decision-making and delivery of health care