Series Health Transitions in Pakistan 4 Health reform in Pakistan: a call to action Sania Nishtar*, Zulfi qar A Bhutta*, Tazeen H Jafar, Abdul Ghaff ar, Tasleem Akhtar, Kaiser Bengali, Qazi Asmat Isa, Ejaz Rahim Pakistan’s enormous macroeconomic, internal, and human security challenges coexist alongside the opportunity Lancet 2013; 381: 2291–97 created by a huge desire for change. With democracy taking root and a new constitutionally ushered era in state Published Online governance, The Lancet Series about Pakistan and health focuses on health as a nation-building and social-welfare May 17, 2013 agenda at a time of unprecedented social upheaval and economic hardships in the country. We call for a unifi ed vision http://dx.doi.org/10.1016/ S0140-6736(13)60813-2 for the goal of universal and equitable health access. We provide recommendations for six objectives for policy and This is the fourth in a Series of action. Higher political priority for health, increased investments, a combination of targeted and universal approaches, four papers about health action in terms of the social determinants, institutionalisation of the right organisational network, and frameworks transitions in Pakistan for accountability are crucial for the attainment of the health goals in Pakistan. *Joint fi rst authors Heartfi le, Islamabad, Pakistan Introduction cover fi nancial support and the achievement of equity for (S Nishtar PhD); Government of Pakistan is a kaleidoscope of hope and despair, and the country’s diverse population in terms of sex, ethnic Pakistan, Islamabad, Pakistan obscurantism stymying progress, frequently manifest origin, and socioeconomic classes. We recommend six (S Nishtar); Division of Women and Child Health, Aga Khan in the courageous faces of young people who want objectives for policy and action that the federation and University, Karachi, Pakistan change. Despite a history with several periods of military the provinces should focus on over the next decade. (Prof Z A Bhutta PhD, dictatorships, the previous parliament was the fi rst ever Prof T H Jafar MPH); Alliance for Health Policy and Systems elected to complete its tenure; elections are scheduled Political ownership of health Research , Geneva, Switzerland in May, 2013. Pakistan still has complex challenges. The Health has never been a political priority in Pakistan, as (A Ghaff ar PhD); Peshawar, wars along Pakistan’s northern borders, regional evident from the persistently low fi scal support. Party Pakistan (T Akhtar FRCP); instability, prob lems with internal security, economic manifestos generally do not present specifi c fi scal solu- Karachi, Pakistan (K Bengali PhD); Pakistan decline, and persistent energy defi cits, have taken a tions that can enhance investments in health; table 1 Poverty Alleviation Fund, huge toll on the country and its population. Weak summarises the key features of political party manifestos Islamabad, Pakistan governance, uncon trolled population growth, and that were made public before April 15, 2013. Some of the (Q A Isa PhD); and Islamabad, natural disasters have also aff ected all dimen sions of political parties have explicitly outlined their plans for the Pakistan (E Rahim MA) health and human development. health sector in manifestos for the forthcoming election. Correspondence to: Yet, the Pakistani society is remarkably resilient and However, with few exceptions, there has been no robust Dr Sania Nishtar, Heartfi le, 1 Park Road, Chak Shahzad, there are developments that bode well for the future. public debate about the issues and possible solutions. Islamabad 44000, Pakistan Pakistan’s demographic resources remain untapped. Various initiatives, which had the potential to reform sania@heartfi le.org The advent of judicial activism and its foray into human health, were hampered by policy vacillations and several or rights issues and public policy have led to the realisation changes in government (panel). The time is now right to Prof Zulfi qar A Bhutta, Centre of of the right to health. A free and open media, and have a consensus about key issues including health and Excellence in Women and Child support for democracy have created opportunities for education and move forward. We call on political stake- Health, Aga Khan University, Stadium Road, Karachi 74 800, public debate and social change. Despite its hasty imple- holders to convene an all-parties conference on health to Pakistan mentation, the 18th Constitutional Amendment to achieve consensus for needed actions with multi stake- zulfi [email protected] devolve education, health, and substantial resources to holder ownership and oversight of the pro cess. Importantly, the provinces has created an opportunity to reform commitment is needed on an agreed set of actions. governance and improve accountability in many sectors including health.1 Increased overall public spending on health In a rapidly changing environment, rarely have the The public sector spends 0·9% of Pakistan’s gross Pakistani people had the luxury to take stock and generate domestic product (GDP) on health—low by any stan- the political and public support to address the closely dard.2 The health indicators are also poor, with rates of intertwined issues of health, human security, and infant and maternal mortalities much higher than develop ment. The Lancet Series about Pakistan and the goals set by the Millennium Development Goals health provides an opportunity to undertake an analysis (MDGs),3 and high rates of non-communicable diseases of the past and present and off er options for the future. in young adults leading to loss of national productivity.4 In this call to action, our aim is to build on the other Public investments by the federation and provinces reports in this Series2–9 to help renew Pakistan’s com- should increase to at least 5% of GDP by 2025 as mitment to health, with the focus on equitable and committed by some political parties. Even in the universal health access as the goal. Because of the huge existing constrained setting, spending on health could challenges resulting from the diff erentials and inequities be increased if resources are managed better. For in Pakistan, the focus on universal health access should example, despite obvious solutions to free up these www.thelancet.com Vol 381 June 29, 2013 2291 Series Key messages • At a tumultuous time in Pakistan’s history, the synergy • Creation of a federal health information hub linked between the forthcoming 2013 parliamentary elections and to the health division. societal demand for change can help to put health on the • Transparent governance and adequate resourcing of nation-building agenda. regulatory, research, and capacity building institutions. • In addition to being a future vision, equitable, universal • Policy for human resources in health that complies health access can be the much needed indicator of domestic with the 18th Constitutional Amendment (agenda policy and goal for Pakistan’s health system. shared by the federation and provinces). • Devolution of health to the provinces by the 18th • Steps needed at the provincial level outside the Constitutional Amendment off ers unique opportunities for health sector: action and accountability, but requires sound planning, • Accountability and performance-promoting culture resourcing, organisational reform, and oversight at federal in the local government. and provincial levels. • Earmarking of a service tax for welfare and health (to • Many institutional arrangements are still in fl ux while a increase money for health). democratic transition is underway. The disarray of the local • Establishment of compulsory health insurance government system adds another level of complexity. In this schemes for formally employed individuals (to setting, we propose an institutional and organisational increase money for health). framework for health. Additionally, the following steps are • Improvements in fi nancial access to health equity deemed necessary to reform health over the next funds for individuals who are poor (to increase parliamentary term. money for health). • Steps needed at the federal level outside the health sector: • Innovations in the existing social protection • Overcoming Pakistan’s fi nancing emergency (to programmes to risk protect the poorest individuals increase money for health). from health shocks (to increase money for health). • Stakeholders’ consensus on a direction for the health • Investment in public health diagnostic capabilities. sector through an all-parties conference. • Steps needed at the provincial level in the health sector: • Interprovincial equity-promoting innovations in • Provincial policies for strategies to achieve universal the National Finance Commission Award (to health access. increase money for health). • Adequate and sustainable support for provincial health • Adequate resourcing and autonomy of health reform and policy units, and public health schools. institutions. • Policy for human resources in health that complies • Increase in excise duty on cheaply sold cigarettes with the 18th Constitutional Amendment (agenda and channelling of revenue towards initiatives for shared by the federation and provinces). prevention of non-communicable diseases (to • Improved resourcing and management of public increase money for health). service delivery facilities. • Introduction of nutrition and maternal, newborn, • Introduction of programmes for population and child health in the national income support planning, non-communicable diseases, and programme. integration