Yet another Health Policy

by

Dr Ghayur Ayub

Sherry Rehman, who holds the health portfolio as additional charge, announced a new health policy the other day. The question in my mind is; why is she in such a hurry to table a new health policy? The little I know about her with our contacts at CoD and ARD meetings in London, she doesn't seem to be a lady who is usually in a 'ush'. Before elaborating on this point let me write a few words about the health policies of Pakistan. 

The first health policy was formulated in the mid 80s and was introduced in 1990. It did not adequately cover all areas of Primary Health Care according to Health For All (HFA) strategy of WHO. In December 1997, the Cabinet of Prime Minister, Mr Nawaz Sharif, approved the first comprehensive National Health Policy based on the new definition of health as described by WHO at Alma Ata in 1978. The aim was to provide universal coverage of quality healthcare through an integrated Primary Health Care approach to promote preventive healthcare without ignoring its curative aspect and making good governance as primary target with special emphasis on strengthening the district health system through decentralization policy of the government using the available facilities. 

Based on that principle, the policy was designed on; rationalizing human resource development; giving greater responsibility to private sector in health delivery services; empowering community to take active role in the decentralized health system; making health planning scientifically based on research; making the health sector responsive to the current and future challenges; giving priority to the vulnerable and disadvantaged groups through social uplift programs; addressing the health problems in the community by providing, promotive, preventive, curative and rehabilitative services to which the entire population has effective access; improving the utilization of health facilities by bridging the gap between the community and the health services; expanding the delivery of reproductive health services including family planning both in urban and rural areas; to gradually integrating existing health care delivery programs like EPI, Malaria control, TB, nutrition and MCH within the Primary Health Care (PHC); improving the nutrition status especially of mothers and children and reduce the prevalence of the malnutrition and to promote intersectoral action and coordination at all levels; and providing an overview of the health sector in the country that gives guideline for action in all priority health areas with vision up to the year 2010. 

The main strategies were structured on; strengthening the district health system and provide necessary support mechanism in terms of training, and logistics to effectively supervise the performance of health workers at all levels.; ensuring satisfactory staff levels at Rural Health Centers (RHCs) and Basic Health Units (BHUs) and promote the deployment of the female workers as human resource; improving the function of referral system to ensure equitable accessibility to emergency, secondary and tertiary heath care services; ensuring effective community involvement and bringing about coordination and collaboration between health and the other government sectors and the NGOs; introducing alternative approaches to financing health care through involvement of the private sector and the national health care schemes having mechanism of strict supervision, monitoring and accountability; integrating all vertical programs into Primary Health Care (PHC) at the operational levels; promoting innovative control strategies for the prevailing communicable diseases such as tuberculosis, malaria, HIV, viral hepatitis, acute respiratory infection (ARI) and diarrhoeal diseases; undertaking the control of major prevalent non-communicable diseases such as cardiovascular diseases, blindness, diabetes, cancer; taking care of senior citizens; and promoting burns and injury prevention and rehabilitation services as part of the policy. 

Thus a national health policy was built on a structural skeleton having; principle interventions of strict equity to ensure universal provision of PHC services; decentralization to reach the gross root level and giving the community an active participatory role; establish district planning and implementation cells to arrange short refresher courses for DHOs/ADHOs, health managers and administrators on planning and implementation; need-based planning on realistic and participatory approach, keeping in view the situation, cost analysis, reliable data, disease patterns and the environment; linking the planning cells effectively with Health Management Information System (HMIS) based on "create facilities and reduce liabilities" lines and connecting the recurring budget with the development budget; and forming appropriate standing committees as and when required for coordinating external assistance. 

According to the need of the time, the following programs were prioritized for implementation in short span of a few months;

1. PHC & FP with its associated activities
2. National Drug Policy
3. Poverty Alleviation Program based on Basic Minimum Needs program of WHO
4. Pakistan Medical and Dental Council (PM&DC) Ordinance.
5. COME (Community Oriented Medical Education) activity in medical education
6. Dialysis program
7. Epidemic/Disaster Preparedness.(DEWS)
8. Health Management Information System (HMIS)
9. Social Action Program Projects (SAPP) 

In 1999, when the country was targeted by the terrorists with bomb blasts, a few new activities were proposed for inclusion in the policy. They were; mosque and health project; making communication maps especially in tribal belt (this activity was initiated and such a map was made of the border areas of Baluchistan during Immunization Days in 1999); using health activities as tools to counter terrorism; and making nationwide database for multi faceted productive purposes.

After the military takeover in 1999, most of the ongoing activities had retarded. Then, in 2001, the government announced a new Health Policy with 10 salient features, labeled as: "˜concretising the Vision: Ten Specific Areas of Reforms'. It covered; communicable diseases, such as EPI cluster of childhood diseases; TB; Malaria; Hepatitis B; and HIV-AIDS; addressed inadequacies in primary,/secondary healthcare services; removal of professional and managerial deficiencies in district health system; promoting greater gender equity; bridging the basic nutrition gaps in the target-population; correcting urban bias in the health sector implementation modalities; introducing required regulation in the private medical sector with a view to ensuring proper standards of equipment and services in hospitals, clinics and laboratories as well as private medical colleges and Tibb/Homeopathic teaching institutions; create mass awareness in public health matters; improving the drug sector with a view to ensuring the availability, affordability and quality of drugs in the country; and finally capacity building for health policy monitoring in the Ministry of Health. This was called the Health Policy of 2001. 

Again in 2005, the government came up with another NHP with a preamble, "˜The Health Sector Reform agenda is being carried forward in keeping with the strategic direction of the National Health Policy 2001'. It included 9 core programs of; National Program for Family Planning and Primary Health Care; EPI; National AIDS Control Program; Malaria Control Program; National TB Control Program; Nutrition Program; Women Health Project; Prime Minister's Program for Prevention and Control of Hepatitis in Pakistan; and finally, National Program for Prevention and Control of Blindness in Pakistan.  

It turns out that the two "˜Health Policies' were no more than extension of programs taken from the Health Policy introduced by the government of Nawaz Sharif. Why these programs were announced as "˜policies' is beyond me. I did my own investigations and found it was a bureaucratic gimmick to attract the attention of the health ministers and to make it seem as if they were doing something new. For example, when an ex-health minister Nasir Khan found himself loosing credibility, he started working on improving his image; so how better to do that than announcing a new health policy! The then shrewd health secretary formed a special health policy unit employing retired bureaucrats especially from the planning division for this purpose. The unit, as far as I know, is still operative today. Their job is to keep bringing up programs from the Health Policy of 1997 terming it as "˜new health policy' giving a moral boost to the incumbent health minister. Once I asked a key member of this gimmick show why they didn't call them the programs of Health Policy of 1997? To which he replied, "˜linking anything with Nawaz Sharif will put us in hell'. What he said then about the politicians running the Health Ministry is unrepeatable. This brings me back to the initial question of why is Sherry Rehman in such a hurry to table new health policies.  I wonder if smart Sherry is getting trapped like her two predecessors by the mostly retired officials of the health policy unit who want to still prove their "˜usefulness'?