Emerging challenges and health system capacity: the case of non- communicable diseases in Pakistan; a review

Background: Pakistan is facing double burden of disease and the contribution of mortality by non-communicable diseases has over numbered the communicable diseases. The focus of health system of Pakistan is inclined more towards communicable disease and maternal & child health. Therefore, there is a need to review health policy, health sector budgeting and health setup in order to meet the needs of healthcare in context of non-communicable disease. Objective: To review the health system capacity to manage the emerging challenge of non-communicable diseases in Pakistan. Methodology: A thorough literature search on PubMed and Google Scholar was done. Reports from W.H.O, other national and international organizations and government & non-government policy papers were also reviewed. We used following search terms; Non Communicable Disease, Health system capacity, Pakistan. Results: Several health system issues emerged through the review of the health system capacity for NCDs. These included lack of political commitment, services more focused on communicable disease and MNCH, inadequate human resources, lack of inter-sectoral approach, insufficient funding opportunities and fragmented health system. These issues can be addressed through government support for combating burden of NCDs, provision of services for NCD at PHC level, human resource training regarding NCDs and integrated care system. Finance should be allocated for NCDs and existing HMIS should also be used for utilizing information regarding NCDs. Conclusion: Health systems framework to NCD means in summary re-examining the planning and organization of the entire health system, from service provision to financing, from information generation to ensuring adequate supply of pharmaceuticals/technologies or human resources, from improving facility management to performance monitoring

Economic burden of mental illnesses in Pakistan.

BACKGROUND: The economic consequences of mental illnesses are much more than health consequences. In Low and Middle Income Countries (LMIC) the economic impact of mental illnesses is rarely analyzed. This paper attempts to fill the gap in research on economics of mental health in LMIC. We provide economic burden of mental illness in Pakistan that can serve as an argument for reorienting health policy, resource allocation and priority settings. AIM: To estimate economic burden of mental illnesses in Pakistan. METHODS: The study used prevalence based cost of illnesses approach using bottom-up costing methodology. We used Aga Khan University Hospital, Psychiatry department data set (N = 1882) on admission and ambulatory care for the year 2005-06. Healthcare cost data was obtained from finance department of the hospital. Productivity losses, caregiver and travel cost were estimated using socio-economicfeatures of patients in the data set and data of national household survey. We used stratified random sampling and methods of ordinary least square multiple linear regressions to estimate cost on medicines for ambulatory care. All estimates of cost are based on 1000 bootstrap samples by ICD-10 disease classification. Prevalence data on mental illnesses from Pakistan and regional countries was used to estimate economic burden. RESULTS: The economic burden of mental illnesses in Pakistan was Pakistan Rupees (PKR) 250,483 million (USD 4264.27 million) in 2006. Medical care costs and productivity losses contributed 37% and 58.97% of the economic burden respectively. Tertiary care admissions costs were 70% of total medical care costs. The average length of stay (LOS) for admissions care was around 8 days. Daily average medical care cost of admitted patients was PKR 3273 (USD 55.72). For ambulatory care, on average a patient visited the clinic twice a year. The estimated average yearly cost for all mental illnesses was PKR 81,922 (USD 1394.65) and PKR 19,592 (USD 333.54) for admissions and ambulatory care respectively. In the sensitivity analysis productivity losses showed high variability (from USD 1022.17 million to USD 4007.01 million). Assuming a gate keeping role of primary healthcare (PHC) demonstrated a saving of USD 1577.19 million in total economic burden. IMPLICATIONS FOR HEALTH POLICY: This study set out to generate evidence using a low cost innovative approach relevant to many LMICs. In Pakistan, like many LMICs, patients access tertiary care directly, even for illness that can be efficiently managed at PHC level. In economic terms the non-medical consequences of mental illnesses are far greater than medical consequences. Based on these finding we recommend, firstly, that mental illnesses should be prioritized equally as other illnesses in health policy and secondly there needs to be integration of mental health in primary health care in Pakistan

Regulation, quality reporting and third-party certification of healthcare providers

The newly established provincial healthcare commissions in Pakistan have started certification of healthcare providers. The policy-makers perceive that without third-party certification or licencing the healthcare quality will be suboptimal in the country. This paper reviews the current literature on third-party certification and studies objectives and progress of the largest healthcare commission in Pakistan. It analyses the certification role of the Punjab Healthcare Commission and draw lessons for future regulation and strengthening of the quality reporting process. It also documents the short-term and long-term trade-off resulting from the enforcement of quality certification in the absence of appropriate alternative investment in medical training and care provisions in the country for uncertified providers. The paper concludes with a roadmap for future research to improve healthcare regulation in Pakistan

Socio-economic determinants of out-of-pocket Payments on healthcare in Pakistan

BACKGROUND: Out-of-pocket (OOP) payment on healthcare is dominant mode of financing in developing countries. In Pakistan it is 67% of total expenditure on healthcare. Analysis of determinants of OOP health expenditure is a key aspect of equity in healthcare financing. It helps to formulate an effective health policy. Evidence on OOP in Pakistan is sparse. This paper attempts to fill this research gap. METHODS: We estimated determinants of OOP payments on healthcare in Pakistan. We used data sets of Pakistan Household Integrated Economic Survey (HIES) and Pakistan Standard of Living Measurement (PSLM) Survey for the year 2004-05. We developed a multiple regression model for the determinants of OOP payments using methods of Ordinary Least Square (OLS). We mainly used social, economic, demographic and health variables in our analysis. RESULTS: Median household OOP healthcare in the year 2004-05 was Pakistani Rupees (PKR) 2500 (US$ 41.99) in 2004-05. Household non-food expenditure was the single highest significant predictor of household OOP health expenditure. Household features like literate head and spouse, at least one obstetric delivery in last three years, unsafe water, unhygienic toilet and household belonging to Khyber Pukhtonkhwa (KPK) province were significant positive predictors of OOP payments. Households with male head, bricks used in housing construction, household with at least one child and no elderly, and head of household in a white collar profession were negative predictors of OOP payments. CONCLUSION: Our analysis confirms earlier findings that economic status and number of old aged members are significant positive predictors of OOP payments. This association can direct government to enhance allocations to healthcare and to include program focusing on non-communicable diseases. Our findings suggest further research to explore beneficiaries of government healthcare programs and determinants of high OOP payments by household residing in KPK province than other province. The interaction between white collar profession and their economic status in predicting OOP payments is also an area for further research