Punjab has highest under-five and infant mortality rates in region: ADB

Punjab has the highest under-five mortality rate and an infant mortality rate (IMR) in the region, although it compares favourably on maternal mortality in relation to other countries in South Asia. In Pakistan, ADB health report on Punjab revealed that the IMR is higher in rural than urban areas, and among boys than girls (80 for boys and 73 for girls).
Higher levels of women's education and household wealth correlate with a lower IMR and maternal mortality ratio (MMR). At the national level, ADB report pointed out that Pakistan recognises the need to improve health outcomes as an important part of the government's poverty alleviation plan. Pakistan's National Health Policy 2001 prioritises primary and secondary healthcare and emphasises the need for good governance as the basis of health sector reform. However, the national policy has not been implemented effectively because of resource and capacity constraints and the absence of a concrete action plan with measurable outputs. As a result, Pakistan compares poorly on infant and maternal mortality indicators among the South Asian countries. Pakistan also lags behind comparable countries with respect to public as well as private expenditures on health.
In Punjab, ADB report mentioned that the health system consists of two parallel streams. The budget-based public health system provides healthcare to any user of a public facility, with negligible official user charges. The private healthcare system is largely unregulated and charges fees for services.
Qualified private providers mainly cater to urban populations who can afford the fees. Public sector spending accounts for less than 20 percent of total expenditures, with privately provided and procured healthcare dominating the sector. Yet, for the rural poor, public health facilities are often the only choice for receiving qualified and affordable medical care, ADB report pointed out.
Despite the massive network of public primary and secondary health facilities, ADB report stated that the coverage of basic health services remains low. The reasons for low coverage of basic health services include limited availability and low quality of services, and sub-optimal health-seeking behaviour. Public primary healthcare has been largely under-utilised mainly because of the absence of doctors, unavailability of drugs, and unreliable and poor quality of services. The biggest obstacle for improving quality is the absence of doctors and paramedics and the poor quality of their training. The day-to-day management of health services has suffered from inadequate capacity, challenges in recruiting and posting motivated doctors and other professionals in rural and remote areas, rigid administrative procedures, inefficient and lengthy procurement processes for drugs and medical supplies and lack of performance monitoring to identify problems and solutions periodically. With health sector spending less than two percent of total public expenditures, the public health service has been severely under-financed, and the limited resources available have not been effectively allocated or used.
Public health service in Pakistan is financed and managed by governments at three different levels - federal, provincial, and district. The Punjab Local Government Ordinance 2001 (PLGO) devolved responsibility for primary and secondary health service delivery to district governments. However, this devolution was not supported by sufficient structural changes and capacity building efforts for the health department, especially for the office of director general, health services (ODGHS) and for district governments. District governments remain dependent on provincial fiscal transfers.
Although budget planning and execution is transferred to district governments, there is limited planning and management capacity at district health departments. The approval of health workers' posts in primary and secondary healthcare facilities largely remain with the health department, not with district governments, while the recruitment of lower level posts has been shifted to district governments' responsibility. No mechanism has been developed yet to monitor the performance of the district health departments, ADB report disclosed.
According to ADB report, federally-financed health programmes have their own implementation and reporting mechanisms, and their co-ordination and information sharing with district health departments is often limited.
Update statistics reports illustrate the key challenges facing the attainment of the two critical health MDGs in Punjab. In summary, the delivery of maternal, neonatal and child health (MNCH) service in Punjab suffers from three main problems: (i) low quality and uneven adherence to service delivery norms, (ii) poor management of health service delivery, and (iii) inadequate financing and weak fiduciary systems.