Provision of appropriate health care services is the center of concern for developed as well as for developing countries. World Health Organization WHO has one of the absolute mandates is to strengthen the health system of countries. Many countries are striving hard and looking for innovative ways to improve their health system. However, some countries are failed to maintain proper health care system, which lead to increase the overall burden of health care. Therefore, it is important to explore and analyze the health care system. This paper aims to conduct a comprehensive analysis of Pakistan Health Care (PHC) system with Sweden Health Care (SHC) system which will includes their brief overview, organization environment which comprises of (goals, expectations, resources, technology), authority, power, status structure, decision making process, primary problems / challenges and some of the strategies for problem resolution.
Brief Summary and Overview
Pakistan is located at Southern Asia having four provinces and126 districts. Pakistan estimated population by July 2011 is over 187, 343 million, with the growth rate of 1.6% and expected to be doubled by 2050 (WHO, 2009). Presently, Pakistan ranks at sixth most-popular country in Asia. The projected population of rural areas estimates (63.1%), whereas for urban areas is 36.9%. The vital statistics includes crude birth rate (CBR) 27.5/1,000 live birth, crude death rate (CDR) is 7.3/1,000 death, and total fertility rate (TFR) is 3.58 children/woman, and infant mortality rate (IMR) estimates 70.9 (World Bank, 2009).
Good health services are those which can provide effective, safe, superior, and quality interventions to those who are in real need. "A health system consists of all organizations, people and actions whose primary intent is to promote, restore or maintain health. It includes all those activities which assist in improving health facilities" (WHO, 2000). This approach must ensure that these health care services should be efficient, superior, and fairly distributed (Shaikh et. al, 2010). PHC system has split between low-cost government-funded hospitals, which are offering only basic services and expensive private-care institutions. According to USAIDS (2012), the government of Pakistan (GOP) has invested very minimum 0.8% of Gross Domestic Product (GDP) on health, including public and private expenditures. In public health care system, Pakistan has numerous problems such as resource scarcity, structural fragmentation, and gender insensitivity. Approximately 66% of people living in rural areas of Pakistan have poverty, illiteracy, and inadequate health care system (World Bank, 2002). Hence, Pakistani population is facing difficulties to access quality health care.
Sweden is a Scandivian country located at northern Europe, connected to Denmark by Tunnel Bridge and its borders are touching Norway and Finland. The capital of Sweden is Stockholm, which is largest city; covers an area of 450, 295 square km and considered as the country of peace. It has highly developed economy and considered as world's eighth highest per capita income. The total population of Sweden estimates about 9.5 million in February 2011 with the annual growth rate of 0.7%. The vital statistics includes CBR: 11.8 births /1,000, CDR: 9.5 births /1,000, TFR: 1.90 children born /woman, IMR: 2.75 deaths /1,000 live births. According to UN, it has third lowest infant mortality rate in the world. Life expectancy of Sweden is among the highest in the world, 83.2 years for women and 79.1 years for men. Leading causes of mortality in Sweden are due to disease of the circulatory system and cancer. Approximately 37% of women and 40% of men deaths occurred due to disease of the circulatory system, whereas 23% of women and 27% of men, deaths due to cancer in 2009 respectively (National Board of Health and Welfare, 2011).
Globally, SHC system is organized and believed on the top of ranking in regard to their healthcare. It is mainly government-funded, although private health care also exists. The Health care expenditure is mainly tax funded (80%) that is equivalent to 9.9% of GDP. The overall % of health cost covered by government is 84.9% (Statistics Sweden, 2011). Under the Sweden constitution, health is primarily responsibility of provincial government. However, the federal government is responsible for formulating and planning the policies related to health system.
SHC system has three levels: national, regional, and local. Number of initiatives at national and local levels implemented to improve and meet the needs of health care system. At national level, the ministry of health establishes guidelines and policies for medical care. At regional level, the responsibility of financing will regulate by general bodies. Finally, at local level municipalities are responsible for maintaining the considerable environment for the citizen of country. There are three independent government levels: national level, 17 country councils/regions, and 290 municipalities. The main responsibility of country councils is to arrange funds and provide (90%) of health care services to the populations. Remaining (10%) of services are provided by municipalities to meet the care for older and disabled people (Sweden Health Care Delivery system, 2009).
The Organizational Environment
Goals
In 1977, Health for All is the prime goal proposed by WHO, to ensure the health and well-being of the people around the world (WHO 2000). Alma Ata declaration was adapted on Primary health care in September 1978. Its aims were to promote and protect the health of all the people, keeping in mind the importance of primary health care (PHC). It is an essential health care, accessible to individual and families at a cost that people can afford. The first Medium Term Development Framework (MTDF), 2005-10 put emphasis to strengthen the preventive, promotive, and PHC (Ikram, 2007). Later, health care goals were revised, and proposed eight Millennium Developmental Goals (MDGs). Its aims were to improve the social and economic conditions of poor countries. However, today by the end of 2012, the attainment of MDGs seems too difficult to be achieved.
WHO defined overall health system goals as: improving the health equity, that are responsive, financially fair, and make the best or most efficient. It provides six building block frameworks to improve efficiency and to achieve desirable health outcomes. It includes services delivery, health workforce, information, medical products (vaccines), financing, and leadership/governance (WHO, 2007). In health system of Pakistan consists of Basic Health Unit (BHU), Rural health Centre (RHC), Tehsil Health Quarter (THQ), District Health Quarter (DHQ), teaching hospitals, and federal programs. It includes Lady Health Worker Program, Malaria Control Program, Tuberculosis, and HIV/Aids control Program, Cancer treatment Program, Food and Nutrition Program and Prime Minister Program for Preventive and Control of Hepatitis A & B. In private hospitals, most of the people have to pay variable amount of money, out of their pockets, as it tend to be very expensive. Poor people are deprived from such facilities. Approximately country's 190 million people have little access to health care (Behree, 2012).
On the other hand, SHC system is socially responsible system with the explicit commitment lies with the goal of "Access to good health for all" by Health and Medical Services Act, 1982. SHC system is dedicated to ensure the health of all the citizens is maintained by three major principles of: (1) human dignity, (2) need and solidarity, and (3) cost-effectiveness. Firstly, human dignity refers to the principle in which all the individuals are treated equally with self-respect regardless of their race and culture. Secondly, the principles of need and solidarity implies that those individual who are in greatest need, must be entitled to access medical care on priority basis. Finally, the principle of cost-effectiveness means that an individual has right to make choices of their health care from different options, by measuring the cause of effect relationship (Anell, Glenngard, & Merkur, 2012). It seems more effective than Pakistani health care system. Moreover, Sweden national public health policy is based on 11 objectives covering the essential determinants of public health. These includes: (1). participation and influence in society, (2). economic and social prerequisites, (3). conditions during childhood and adolescence, (4) health in working life, (5) environments and products, (6) health-promoting health services, (7) protection against communicable disease, (8) sexuality and reproductive health, (9) physical activity, (10) eating habits and food, and (11) tobacco, alcohol, illicit drugs, and gambling (Sweden National Institute of Public Health, 2011).
Expectations
The expectations of Pakistani health care needs are continuously changing as compare to the past 50 years. Due to increasing demands of health care, people are raising their voices and become aware about the impact of their health. They have complete right to choose, decide and raise their concerns about the services, provided them. They also expect confidentiality while making decisions about their health status. Hence, health care systems have vast responsibility not only to improve their health but also treat them with dignity and respect. However, due to certain limitations like political, social influence, improper management of disasters, and law-and order situations this seems difficult on the same level of health continuum. Whereas, SHC system implies the responsibility and expectation to ensure that every individual living in Sweden should get access and provision of good health care facilities. Sweden has appointed eight government agencies, which are working directly on the development of health related policies in the area of public health. The country councils, regional bodies, and municipalities are expected to generate funds in order to meet the health services and housing needs of their populations. Besides this, health service staff is also expected to work by utilizing scientific based knowledge during their clinical experience. National Board of Health and Welfare have provided the evidenced-based guidelines for the care and treatment of patients with chronic illness and disease.
According to Sweden and Medical Services Act 1982,
"Health and medical services are aimed at assuring the entire population of good health and of care on equal terms. Care shall be provided with due respect for the equal worth of all people and the dignity of individual. Priority shall be given to those who are in greatest need of health and medical care."
(Sweden Health Care Delivery System, 2009)
Human and Material Resources
In Pakistan, the domain for an effective health care system delivery depends on the delivery of resource inputs. It could be human, financial, material or organizational. One of the major resources, which largely depend on efficient health care, is the provision of financial inputs. Large numbers of physicians, nurses, and other allied health professional are useless without adequately well-constructed equipped supplies and facilities (WHO report, 2007). Resources should be allotted to invest on new skills and to maintain the existing infrastructure. It is also important to allocate resources according to the needs of population.
According to the social indicators of Pakistan, (2011) the estimated numbers of doctors (144,901), dentist (10,508), nurses (73,244), Lady Health Visitors (11,510), Midwives (26, 225), and registered Hakeem's (797). Looking at the health facilities in Pakistan there are total 13,937 health facilities, in which hospitals (972), dispensaries (4,842), MCH centre (909), RHC (577), BHU (5,345) and beds in hospitals and dispensaries are (104, 137). These human resources must be treated as a capital physical investment, with proper education and training as the key tools for acquire knowledge and skills. Pakistan lacks investment in such activities which can decrease the new knowledge in the professionals of our country. Health care system can work better if clinical and non-clinical staff acquires new knowledge, skills, and motivation from the country. On the other hand, in Sweden, more human resources allocated to the health sector than other European countries. A large proportion of resources are made available for medical services for the provision of better care and treatment at hospital level. According to Anell., et al. (2012), there are 25, 500 hospital beds, with more than 4400 in psychiatric care and about 1100 in private hospitals and 70 hospitals at country level in 2009.Also, the number of professionals in Sweden are above average than other European countries. On average, there are 35, 000 registered physicians, 115, 000 registered nurses working at municipal and private sectors. The consultation fees for primary care services varied between SEK 100 and 200, for specialist consultation between SEK 230 and 320 in 2011. Patients who are admitted in hospital will be charged SEK 80/day, whereas these charges are exempted for patients under the age of 20 years. There are 1200 pharmacies throughout the Sweden providing prescribed and non-prescribed drugs to the entire population group.
Technology
In general, every country needs well-equipped facilities with latest technology as well as strong Health Management Information System (HMIS) to have better health care outcomes. It includes new drugs or diagnostic equipment to solve health related problems. Old out-dated investments needs to be replaced with new improved technologies. Every assets have certain lifetime, with proper timely maintenance of the assets gives lives to the equipment. In Pakistan, many hospitals have access to the advanced, well-equipped facilities of latest technologies and HMIS like Aga Khan University hospital (Khowaja, 2009). It is the only hospital, who invest ample amount of money not only in getting access to the latest technologies but also arrange continue education and on-job training for staff to keep existing skills in line with technological progress.
In contrast, recent changes in SHC system is the shift from hospital inpatient care to outpatient care. In primary care, only basic health care facilities are provided and they do not require any advanced medical equipment of technology. On the other hand, private hospitals provide specialized care requiring medical equipment and other technologies that are not accessible at primary level. Sweden Council on Technology assessment on health care (SCTHC) has the prime mandate to evaluate all necessary health care technology. This review is based on benefits, risks, and cost of technology and identifies which method is the most appropriate and best to treat the specific disease. Their HMIS system is very organized in which every citizen and immigrates have their own personal identification number, where all the health information can be easily accessible to the authorized personnel only.
Besides this, government invests some portion of funds for national insurance scheme for the residents of Sweden. It covers medical expenses, hospital admission bills, sick benefits, and dental costs. Also, fees are subsidized for disabled, special people and chronic patient.
Authority, Power, and Status Structure
Pakistani health care system is partially vertical and horizontal. Vertical segmentation is shown in a way in which individual organizations such as federal health ministry, provincial ministry, non-governmental organization, private sector healthcare providers, armed forces, and employees social security institutions nurture and allocate their own funds, pay their own providers and deliver services (Nishtar, 2006). In some cases, these are actually vertical as they aid populations like armed forces and social security. The system is also horizontally array in many areas, for example, in the case of the Federal Ministry of Health and the national programs and institutions that fall within its jurisdiction.
The main role of the federal government is to make policy, provide technical support, coordinate, plan training, run national health programs and to seek assistance. In contrast, provincial government is responsible for delivery and management of health care services within the province. Different tasks in the health sector are entrusted to the Ministry of Health at federal level and departments of health at provincial level. These are assigned to guide and regulate other organizations that are horizontally integrated with them and other vertically aligned health systems (Nishtar, 2006). Health care has been provided at three different levels (primary, secondary, tertiary levels) and through public health programs. Nevertheless, most people receive healthcare through private out of pocket and payments are directly provided. Therefore, taxation, donors contributions, and out of pocket payments are the major modes of financing health in Pakistan. Traditionally, a policy cycle links processes like coordination, consensus building, decision making, policy development, identification, implementation, and evaluation of the issues. Analysis and interpretation again loop into consensus building, thus completing the policy cycle. Based on this model expressive to the current configuration of health systems in Pakistan, the ideal health policy cycle should follow the pattern represented in Figure 1 (Appendixes 01). However, in reality, there are gaps in coordination between policy formulation and its effective implementation.
Besides this, Sweden has much socialized health care system last fifty years. Most of the funding comes from the government and majority of the health care facilities like hospital based, primary health care, and prescribed drugs are controlled by government. Since 1955, national government has given complete authority to the country councils (Hogberg, 2007). Country councils have more power than national and municipal government. However, national government still has an important role. Together with national government, ministry of health and social affairs are responsible to supervise the health activities of the country councils efficiently. It also provides advice to Swedish parliament on legislative regarding health. They are responsible for the delivery of health care system from primary level to the hospital level. Also, they holds complete authority over the hospital structure (Hogberg, 2007).Municipal government have given responsibility to care for the patients, who have discharged from hospitals, and also responsible for the care of the nursing homes patient.
Decision making process
In Pakistan, the development of health policy and making its operational plan is an important aspect of the policy process. The decisions are also made at different level regarding the implantation of the program. Effective implementation of policies and decision making needs strong governance, institutional strength, accountability process, effective and transparent health system. Appendix 2 explicitly describes the decision making process in Pakistani context. Decision making process is not only followed at federal level but also at provincial level. At the provincial level, the key position holders which hold responsibility are ministers, directors, managers, principals, and superintendent of various levels.
The health minister and director general health are responsible to look after the health care services of the province. The Chief Executive and Medical Superintendent looks after the responsible within their facility domain. All these facilities and management are affected by the external forces mostly political. Managerial authority, decision making, political and external inferences, and stake holders are the main characters of the decision making process. For example, in the process of recruitment, transfer, disciplinary actions, project funding, and appraisal provides impact on the quality and efficiency of decision making. This is one of the demoralizing factors within the public sector.
In Sweden, regional and local authorities are represented by a state, which is responsible for the overall health care policy named Swedish Association of Local Authorities (SALAR). Sweden Single payer, universal healthcare system, with 21 county councils as the primary payer and administration of healthcare plan is decentralized in the hands of the county councils. Central government's role is to give grants to councils for the proper delivery of care processes mainly to the public and private practitioners, whereas hospitals are mostly independent public facilities. There are eight governmental agencies involved in the area of health care. It includes (1). National Board of Health and Welfare, (2) Medical Responsibility Board, (3). Swedish Council on Technology Assessment in Health care, (4). Medical Products Agency, (5). Dental and Pharmaceutical Benefits agency, (6). Swedish Agency for Health and Care Services Analysis, (7). Swedish Social Insurance Agency and finally (8). National Institute for Public Health (Anell, et., 2012).
Primary Problems Challenges and their strategies
Pakistan….
Looking critically at the SHC system, there are certain problems, which need to be addressed. First of all, the life expectancy of Sweden is increasing since 2009 and it has been more apparent that the number of elderly adults is increasing day by day. This creates an enormous implications on the Swedish Department of Social Affairs, 1995), that they need to develop more nursing care do that the standard of nursing care can be provided. Secondly, the number of health care professionals is migrating to other European countries for longer period of time has been increased. (Gennser, 1999) have identified that the conflicts between financial demands is the major cause of this issue. This will results in gross reduction in providing quality health care and increase the problem of waiting times in the patient care area. To solve this issue, Swedish government has to find some innovative strategies to stop this burning issue. It could be increasing the managerial and administrative positions and also to provide them other attractive benefits. Thirdly, the responsibility lies with the National Institute of Public Health is to maintain and achieved desired results on public health objective (already mentioned on page 5), so that health for all is achieved. Besides this, the focus should be placed on the improving the coordinated care to older people, for last 10 years, SALAR has working very actively to sort all those issues related to health care delivery.
Strategies for Problems and challenge Resolution (Sweden Pakistan wise)
Strengthening the role of the State as the principal steward of the health system.
Priority settings for the use of public funds need to be universally available.
Develop alternative service delivery and financing options for the provision of healthcare.
Maximizing efficiency in the same system or transferring management to lower levels.
Building the capacity and deploying of human resource effectively.
Establishing a conducive and rewarding working environment and initiating measures to redress imbalances with regard to the existing staff.
Establishing Public- private partnership in order to foster intra-collaborative arrangements with the mandate to offer public good.
Building conscious safeguards in order to offset the risk of creating access and affordability issues for the poor in the new service delivery arrangements.
Establishment of social health insurance as part of a comprehensive social protection.
Strengthening of waiver and exemption systems to provide subsidies to poor patients.
Institutionalizing civil service reforms centered on good governance, accountability, crackdown on corruption, mainstreaming managerial audit and building safeguards against political and external interference.
Developing alternative health policy inter-sectoral scope with careful attention to the determinants of health and contemporary considerations that influence health status.
Redefining targets within the health sector to get support from across various sectors.
Creating inter-sectoral agencies that concentrate on prevention and health promotion at multiple levels legislative, ministerial and others as necessary.
Development of dedicated provincial agencies that implement such programs and overarching policy and legislation for health promotion.
References:
Akram, M. & Khan, F. (2007). Health Care Services and Government Spending in Pakistan.
Pakistan Institute of Development Economics, Islamabad. Retrieved from
www.pide.org.pk/pdf/Working%20Paper/WorkingPaper-32.pdf
You +1'd this publicly. Undo
Anell, A., Glenngard, A., Merkur. S. (2012). Health System in Transition: Sweden Health
System Review. 14(5). Retreived from www.euro.who.int/__data/assets/pdf_file/0008/.../e96455.pdf
Bahree, M. (November 6, 2012). Bringing Health Care to More Pakistani. The Wall Street
Journal. Retrieved from http://online.wsj.com/article/SB10001424052970204846304578090713421035962.html
Four Health System Organization. (2000). Retrieved from
gis.emro.who.int/HealthSystemObservatory/.../Pakistan/
Glenngard, A. H., Hjalte, F., Svensson, M., Anell, A., & Bankauskaite, V. (2005). Health
systems in transition. WHO Regional Office for Europe on behalf of the European
Observatory on Health Systems and Policies, Sweden, Copenhagen.Health Systems
Gennser, Margit. Sweden's Health Care System. 1999. <www.fraiserinstitute.ca/publications/books/health_reform/sweden.html.>
Islam, A. (2002). Health Sector Reform in Pakistan: Future Directions. Journal of Pakistan Medical Association, 52(4), 174-182.
Khowaja, K. (2009). Healthcare Systems and Care Delivery in Pakistan. Journal of Nursing
Administration, 39(6), 263-265.
Shaikh, B., Rabbani, F., Safi, N., Dawar, Z. (2010). Contracting of primary health care
services in Pakistan: Is up-scaling a pragmatic thinking? Journal of Pakistan Medical Association, 60(5). 387-389.
Social Indicators of Pakistan 2011. (6. Ed.). Government of Pakistan: Federal Bareau of
Statistics. Retrieved from www.pbs.gov.pk/sites/.../social.../social_indicators_2011/preface.pdf
Sweden retrived from http://en.wikipedia.org/wiki/Sweden
USAIDS/ Pakistan. (2012). Pakistan Mission Annual Program Statement: Health Systems
Strenghtening (HSS) Project. Retrieved from transition.usaid.gov/pk/.../HSS/Pakistan_HSS_Project_APS_final.pdf
World health Organization. (2007). Strengthening Health Systems To Improve Health
Outcomes: Who's Framework For Action. Retrieved from www.searo.who.int/.../Health_Systems_EverybodyBusinessHSS.pdf
World health Organization. (2000). The World health Report 2000. Health Systems:
Improving Performance. Retrieved from www.who.int/whr/2000/
Noor….
Birdsall N (2003). Ignorance should not be bliss: policy research on health systems and health services in the developing countries. Proceedings of the Global Health Forum Meeting; 2003 Dec 07; Geneva, Switzerland.
Hogberg, D. (2007). Sweden's single-payer health system provides a warning to other nations. Retrieved from http://www.nationalcenter.org/NPA555_Sweden_Health_Care.html
Government of Pakistan (2005). National Plans. Islamabad: Planning Commission; Retrieved from
http://www.pakistan.gov.pk/divisions/index.jsp?DivID=18&cPath=16
Government of Pakistan (2005). Medium Term Development Framework 2005-10. Islamabad: Planning Commission.
Kronstrom, C. (1999). The Swedish Health Care System. International Market Insight.
Nishtar S (2006). The Gateway Paper; Health System in Pakistan - a Way Forward. Pakistan's Health Policy Forum and Heartfile; Islamabad, Pakistan.
World Health Organization (2005). Building stronger health systems: key to reaching the \ Millennium Development Goals. Geneva, Switzerland: World Health Organization.
World Health Organization (2000). The World Health Report 2000: Health Systems: Improving Performance. Geneva, Switzerland: World Health Organization.
Appendix 01
Figure 1. Pakistan's current health policy formulation process
Reference:
Nishtar, S. (2006). The Gateway Paper; Health System in Pakistan - a Way Forward Figure
01. p.05
Appendix 02
Figure 02, Decision making process in health care sector
