PAKISTAN HEALTH

CARE SYSTEM
Community Health Nursing-I

Imran Waheed/ Zafar Iqbal

Lecturers
(INS-KMU)
 Objectives
By the end of presentation, learners will be able to:
• Define System , Health Care System
• Identify the Health Services available to community
by Pakistan Government Health Care System
• Explain the roles of Health Care Team members
within the Health Care System
• Discuss the Devolution Plan of 2000
 System
• A set of things working together as parts of a
mechanism or an interconnecting network; a
complex whole.
• An organized, purposeful structure that
consists of interrelated and interdependent
elements (components, entities, factors,
members, parts etc.).

8/30/2021 Imran Waheed 3

 Health System
• A health system, also sometimes referred to
as health care system, is the organization of
people, institutions, and resources that
deliver health care services to meet the health
needs of target populations.
• “All the activities whose primary purpose is to
promote, restore, or maintain health” WHO,
2000

8/30/2021 Imran Waheed 4

 Hospital Systems
• A hospital system is a group of hospitals or facilities
that work together to deliver services to their
communities.
• Different types of hospital systems have different
types of ownership and financial goals.
Types of hospital systems include:
• Public Hospitals
• Non-profit Hospitals
• Private Hospitals

8/30/2021 Imran Waheed 5

 Conti…
Public Hospitals:
• Public hospitals are funded and owned by
local, state or federal governments and
receives money from the government. Some
public hospitals are associated with medical
schools.

8/30/2021 Imran Waheed 6

 Conti…
Non-profit Hospitals:
• Non-profit hospitals are often community
hospitals and may be linked with a religious
denomination. The main goal of a non-profit
hospital is to provide service to the
community.

8/30/2021 Imran Waheed 7

 Conti…
Private Hospitals:
• Private hospitals are owned by investors.
Their goal is to earn a profit. Private hospitals
tend to offer more profitable services such as
rehabilitation, elective or plastic surgery or
cardiology. They try to avoid unprofitable
services such as emergency medicine, which
can lose money due to uninsured patients.

8/30/2021 Imran Waheed 8

 Health infrastructure
• General hospital: A hospital that provides a range of
different services for patients of various age groups
and with varying disease conditions.

• Specialized hospital: A hospital admitting primarily

patients suffering from a specific disease or affection
of one system, or reserved for the diagnosis and
treatment of conditions affecting a specific age
group or of a long-term nature.

8/30/2021 Imran Waheed 9

 Conti…
• District/first-level referral hospital:
• A hospital at the first referral level that is
responsible for a district or a defined
geographical area containing a defined
population and governed by a politico-
administrative organization such as a district
health management team.

8/30/2021 Imran Waheed 10

 Conti…
• Primary Health-care Centre: A Centre that
provides services which are usually the first
point of contact with a health professional.
They include services provided by general
practitioners, dentists, community nurses,
pharmacists and midwives, among others.

8/30/2021 Imran Waheed 11

 Health Workforce
Physicians/doctors:
• All graduates of any faculty or school of
medicine, actually working in the country in
any medical field (practice, teaching,
administration, research, laboratory, etc.).

8/30/2021 Imran Waheed 12

 Conti…
Midwives:
• All persons who have completed a
programme of midwifery education and have
acquired the requisite qualifications to be
registered and/or legally licensed to practice
midwifery, and are actually working in the
country. The person may or may not have
prior nursing education.

8/30/2021 Imran Waheed 13

 Conti…
Nurses:
• All persons who have completed a
programme of basic nursing education and
are qualified and registered or authorized to
provide responsible and competent service for
the promotion of health, prevention of illness,
the care of the sick, and rehabilitation, and
are actually working in the country.

8/30/2021 Imran Waheed 14

 Conti…
Pharmacists:
• All graduates of any faculty or school of pharmacy,
actually working in the country in pharmacies,
hospitals, laboratories, industry, etc.
Dentists:
• All graduates of any faculty or school of dentistry,
odontology or stomatology, actually working in the
country in any dental field.

8/30/2021 Imran Waheed 15

 Conti…
Other health-care providers (including community
health workers):
• All workers who respond to the national
definition of health-care providers and are
neither physicians/doctors, midwives, nurses,
pharmacists, or dentists.

8/30/2021 Imran Waheed 16

 Health Team

• Community health nurse

• Lady health visitor
• Health technician
• Vaccinator
• Dispenser
• Lab technician
• Family health worker

8/30/2021 Imran Waheed 17

 Conti…
• Therapists and rehabilitation specialists
• Emotional, social and spiritual support
providers
• Lady health worker
• Trained traditional birth attendant
• Security guard
• Peon

8/30/2021 Imran Waheed 18

 Conti…
• Sanitary Worker
• Driver of Ambulance
• Other persons, who work for promotion of
health.

8/30/2021 Imran Waheed 19

 Define The Problem

Evaluate Identify Causes

The Health
Systems
Reform Cycle
Implement Develop Options

Decide What to Do
8/30/2021 Imran Waheed 20
PUBLIC HEALTH
SYSTEM
 In General, Public Health
• Prevents epidemics and the spread of disease.
• Protects against environmental hazards
• Prevents injuries.
• Promotes and encourages healthy behaviors.
• Responds to disasters and assists communities in
recoveries.
• Assures the quality and accessibility of health
services.

8/30/2021 Imran Waheed 22

 Public Health Approach

Public Health Model Medical Model

• Population • Individual
• Disease Prevention • Diagnosis
• Health Promotion • Treatment
• Interventions • Intervention
• Environment • Medical care
• Human behavior • Private (Some
• Government (Some public)
private)

8/30/2021 Imran Waheed 23

24
 Level Of Health
There are three levels of health care:
Primary Health Care.
Secondary Health Care.
Tertiary Health Care.
Primary Health Care:
PHC is based on MCH, Dispensaries, Family
Planning Centers, Health House of LHW, and BHU&
RHCS.

8/30/2021 Imran Waheed 25

PHC mostly focuses on prevention and
promotion rather than cure
All elements of primary health care (PHC) are
being practiced in this level.
First aid is also part of PHC.
This level refers the patient to secondary level
for detection and treatment of disease.
Even conduct NVD (Normal Vaginal Delivery)
is a part of this level.

8/30/2021 Imran Waheed 26

 Secondary Health Care Level
It is concerned with early detection of diseases
and prompts treatment.
It is based on Taluka & District Hospitals.
It is more curative level rather than preventive.
It receives the patients from primary health care
level.
It has special services of Gynecologist, Physician,
ENT specialist, Orthopedic surgeon, and
pediatrician etc .

8/30/2021 Imran Waheed 27

 Tertiary Health Care Level
It provides high level of care and provides care to
disabilities and provide rehabilitations.
It receives the patients from secondary health care
level.
It has specialized units and departments psychiatry,
Ophthalmology, ENT, Maternity, Gynecology, cancer
and orthopedics departments etc.
It is equipped with latest technological and
sophisticated machinery.

8/30/2021 Imran Waheed 28

8/30/2021 29
 Health Services Available To
Community By Pakistan Health Care
System

Basic Health Unit:

The basic health unit of primary health care
(PHC), which promotes health & prevents the
disease by immunization, health education,
family planning and treating minor illnesses.
On an average, a basic health unit serves a
population of around 10000–25000

8/30/2021 Imran Waheed 30

It is staffed with:
• One medical officer
• One health technician
• One dispenser
• 5-10 lady health workers, depends on the
periphery area.
• One security guard
• One Dai/ TBA.

8/30/2021 Imran Waheed 31

 Rural Health Center
 It serve a catchment area population of
50000–100000
 It is primary health care unit (PHC) that promotes health,
prevents diseases through immunization, health
education, family panning and treating common minor
illnesses.
 It implement elements of primary health care.
 It also provides the special services of gynecology,&
general surgery in addition to BHU.
 It is integrated with 4-6 basic health units.
 Have a 10- 25 bedded ward.
8/30/2021 Imran Waheed 32
It is staffed with:
• One medical superintendent
• One deputy medical superintendent
• sr, woman medical officer
• Sr, medical officer
• Medical officer
• One gynecologist& obstetrician
• One surgeon
• One staff nurse incharge
• One lady health visitor
• One dispenser
• Store keeper
• vaccinator
8/30/2021 Imran Waheed 33
• One registration clerk
• Two drivers
• Ward servant
Taluka Head Quarter Hospital:
It consisted over the population of 10,0000 or
more
One taluka hospital is integrated with 03-04
RHCs
It is included in secondary health care level

8/30/2021 Imran Waheed 34

It provides prompt diagnosis & treatment of
minor & major diseases
It provides more curative rather than preventive
health care
It receives the patients from the primary health
care facility
It has special services of gynecologist, eye,
pediatrics, ENT including general surgery &
medicine
It has a 25- 50 bed capacity.
8/30/2021 Imran Waheed 35
District Head Quarter Hospital:
It also provides the secondary health care
It is integrated with 4-6 Taluka hospital
It is located at district level and serves 1-3 million
population.
All DHQs provide referral care to patients
referred by BHUs, RHCs and Tehsil Head
Quarters.
Provincial or Teaching Hospital:
All tertiary health care level hospitals.
Also provides medical & nursing education.
8/30/2021 Imran Waheed 36
Provide special care e.g. psychiatry,
 ENT, Neuro-surgery, orthopedic, gynecology,
obstetrics, pediatrics & oncology.
These hospitals prevent disabilities & provide
rehabilitation services also.
These hospitals have more technological devices
& procedures.
These hospitals are under control of provincial
secretary of health directly.

8/30/2021 Imran Waheed 37

 Federal Hospitals:
These hospitals run under control of federal govt
and mostly located in capital city of provinces.
These hospitals provide tertiary health care
services to the people.
Pakistan Institute of Medical Sciences Islamabad
PolyClinic, National Institute of Health in
Islamabad

8/30/2021 Imran Waheed 38

 Conti…
NICHD (National institute of child health )
JPMC (Jinnah postgraduate medical center),
NICVD (National institute of cardiovascular
diseases) in Karachi,
Liaquat medical university hospital in Hyderabad,
Jinnah hospital in Lahore

8/30/2021 Imran Waheed 39

 Role Of Health Care Team Member

1. Immunization against major infectious diseases.

Immunization is the process, which stimulates
certain body reactions to produce antibodies with
manipulation, against the pathogenic organism
and to protect the body from infectious diseases.

8/30/2021 Imran Waheed 40

 Conti…
Vaccine is a suspension of live or dead
microorganisms of the diseases, which
stimulates the immunity system of body to
produce antibodies for the protection of
infectious diseases

8/30/2021 Imran Waheed 41

 2. Prevention And Control Of Local
Endemic Diseases:
Endemic:
Term refers the diseases (or anything resembling a
disease) constantly present to greater or lesser
extent in a particular locality e.g. Endemic malaria,
food shortages and starvation are endemic in
certain parts of the world.

Control And Prevention Of Endemic Diseases:

Surveillance must be done regularly.
Early Diagnosis.

8/30/2021 Imran Waheed 42

Isolation of patients.
Provide sanitation facilities
To kill vectors (disease carrying insects).
Affected individual should keep the piece of
cloth on mouth and nose during sneezing.
Educate the families about the mode of
transmission of communicable diseases.
To teach the general hygiene.
Intimation must b given to district health officer.
8/30/2021 Imran Waheed 43
 3. Appropriate Treatment of Common
Diseases and Injuries:
Common Diseases Are:
• Common cold.
• Allergies
• Skin Rashes
• Cough
• Malaria
• Diarrhea
• Dysentery
• Upper respiratory infections.
8/30/2021 Imran Waheed 44
 4. Provision Of Essential Drugs:

As we discussed the elements of “PHC”

treatment of minor illness, so for
implementation of above element. We need
drugs. These includes:
Analgesic & Antipyretic Drugs:
Tablets and syrups of ,, paracetamol
preparation.
Ibuprofen( brufen) tabs& syrups.
Aspirin tablets.
8/30/2021 Imran Waheed 45
 Conti…
• Simple Antibiotics:
• Caps & syrup: Ampicillin.
• Tabs& syrup: Septran.
• Eye ointment/drops
• Choramphenicol eye drops.
• Neomycin Eye ointment.
• Bandages & Cotton Etc:
• Gauze
8/30/2021 Imran Waheed 46
 Conti…
• Bandage rolls.
• Cotton rolls
• Crepe bandages
• Gloves
• Paper plaster
• Small and disposable antiseptic bandages.
• Polyfax skin cream.

8/30/2021 Imran Waheed 47

 Devolution, Decentralization,
Debundling

• It is the transfer of authority, or disposal of

power in public planning, management and
decision making from the national level to
sub- national levels or from a higher to lower
levels of government.

8/30/2021 Imran Waheed 48

 Main Objective
• Providing the means for community
participation and local self-reliance and
ensuring the accountability of government
officials to the population.

8/30/2021 Imran Waheed 49

Devolution of Powers In Health
Department
Objectives:
• Empowerment of the people at the grass root
level.
• To make the District the dominant level of
decision making in health department.
• Improve the quantity and quality of health
care delivery to the people close to their door
steps.
8/30/2021 Imran Waheed 50
 Conti…
• Integrated approach to public health,
combining, preventive, promotive and
curative health at all levels.

8/30/2021 Imran Waheed 51

 Responsibilities/ Functions at
the District Level
• Prevent and Control Communicable Diseases
and Non Communicable Diseases.
• Food Sanitation.
• Maintain medical and health statistics under
HMIS
• Reproductive Health.
• Health and Nutrition Education.
• Environmental and Occupational Health
8/30/2021 Imran Waheed 52
 Responsibilities/ Functions at
the Provincial Level
• Make Health Policy for the Province.
• Legislate on Provincial health Issues.
• Drugs control under the Drugs Control Act.
• Monitoring and Regulatory functions of
Medical and Para Medical institutions.
• Health Research and related Health
information gathering.

8/30/2021 Imran Waheed 53

RESOURCE/ASSETS DISTRIBUTION
FOR THE DISTRICT
•Type-A or B [DHQ Hospital] hospitals.

•Type-C [Tehsil HQ] hospitals.

•Type-D [Civil] Hospitals

•RHCs.
•BHUs.
•Sub Health Centers.
•MCH centers.
•Dispensaries.
8/30/2021 Imran Waheed 54
 Progress So Far
• Posts in Directorate General of Health Services
have been re-designated
• Budgets according to the new requirements.
• All EDO’s(H) and ADHOs have been briefed by
the department twice on its approved
Devolution plan.

8/30/2021 Imran Waheed 55

 Conti…
• Briefing was held for both EDO’s(H) and DCOs
of all districts by Health Department
• All EDO’s(H) have been instructed to work as a
team with the DCOs at the district level
• All EDO’s(H) have been asked to develop lists
of their assets for distribution

8/30/2021 Imran Waheed 56

ADMINISTRATIVE STRUCTURE:
DISTRICT

District Coordination Officer

EDO: Health

Public Health
District Headquarters Hospitals
Basic Rural Health Centre
Mother & Child Health
Population Welfare
Functions Of Executive District
Officer
• Ensure that the business of the department
and offices placed under his administrative
control is carried out in accordance with the
relevant laws and rules.
• Co-ordinate and supervise the activities of the
relevant offices.
• Ensure efficient services delivery by
functionaries under his control.

8/30/2021 Imran Waheed 58

 District Health Management
Team
What is the purpose of a DHMT ?
Develop a Team approach
Share and Exchange Views
Reduce the workload of the DHO
Optimize Utilization of the Human Resources
Improve Cooperation and Collaboration
among stakeholders

8/30/2021 Imran Waheed 59

 How is a DHMT Constituted
• EDO(H)
• Other District Managers
• Public Sector Health Care Providers
• Private Sector Health Care Providers
• Community or its elected leaders

8/30/2021 Imran Waheed 60

 Role of DHMT
• Sharing of experiences and exchanging of
views & ideas.
• Taking responsibilities and improving
technical efficiency by supporting, assisting.
• Improve cooperation and collaboration with
the Government and private health related
sectors.

8/30/2021 Imran Waheed 61

 Outcomes
• Well-defined structures have been developed
and resources allocated.
• Meaningful partnerships at provincial, district,
tehsil and community level, through the
establishment of DHMT,THMT and citizen
boards.
• Detailed mapping of resources and services
need to be developed.

8/30/2021 Imran Waheed 62

 Conti…
• Well-defined structures have been developed
and resources allocated.
• Meaningful partnerships at provincial, district,
tehsil and community level, through the
establishment of DHMT,THMT and citizen
boards.
• Meaningful action and capacity building
would be required at all levels.

8/30/2021 Imran Waheed 63

Health Expenditure Situation at
Present
• Almost 100% is out-of pocket
• Includes formal and informal private sector
• Questionable quality of care
• Considerable expenditures on unnecessary
and inappropriate (sometimes unsafe) care
• Inequity in financing of care
• No regulation or standards on fee charged
• Reliable information not available
8/30/2021 Imran Waheed 64
 Advantages of Devolved
System in Health Care
• Administrative and financial powers to
district authorities / local bodies
representative.
• Involvement in devising the programs
relevant to the local needs and priorities.
• Strategies and plans acceptable for the
community and matching to their socio
cultural and socio economic background.

8/30/2021 Imran Waheed 65

• User willingness to pay for PHC in the public
sector services, if they receive improved care.
• The districts can recover substantial costs and
can retain the incomes.
• Creating sense of ownership.
• Strengthening of FLCF, answering many
primary health problems like high IMR, high
MMR and morbidity and male involvement.

8/30/2021 Imran Waheed 66

 Criteria for Allocating District
Budgets
• Population Size
• Socio-economic Development
• Health Infrastructure
• Health Needs / Problems (BOD Estimation)
• Performance Evaluation based on
predetermined indicators
• Combination of Above

8/30/2021 Imran Waheed 67

 Challenges and Constraints
• Political willingness of provincial and district
governments to work in the new system.
• Defining their administrative roles with limits
and jurisdiction.
• Distribution of financial powers between
Provincial and District representatives.
(dependency of districts on provinces for how
long?)

8/30/2021 Imran Waheed 68

 Conti…
• Financial and administrative capacity of the
district government.
• Resentment against the status quo at the
provincial level and fear of loosing authority.
• Lack of trust and losing the profit.
• Status of Public Service Commission, Medical
colleges and Tertiary hospitals.

8/30/2021 Imran Waheed 69

 References
• 1.Primary & Secondary Health Care Department. (n.d.). Retrieved
October 26, 2016, from
http://www.pshealth.punjab.gov.pk/Services.aspx
• 2.Wazir, M. S., Shaikh, B. T., & Ahmed, A. (2013). National program
for family planning and primary health care Pakistan: A SWOT
analysis. Retrieved Aug 25, 2021, from
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3842797
• 3.http://www.emro.who.int/pak/programmes/service-
delivery.html
• 4. Analysis of Healthcare Delivery system: Pakistan vs United States.
(2014, June 01). Retrieved Aug 25, 2021, from
http://aeircedu.com/wpcontent/uploads/11download-full-
paper.pdf
70
Aim for the moon. If you
miss, you may hit a star.
(W. Clement Stone)