- Health Care System in Pakistan
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7.1 Public sector, territorial government, civilian part Pakistan's public health delivery system functions as an integrated health complex that is adminis- tratively managed mainly at the district level. Health services delivery is primarily a provincial matter while the Federal Government plays a supportive and coordinating role. Previously, the Ministry of Health was mandated with policy-making, coordination, technical assistance, training, and seeking foreign assistance. However, on June 30, 2011, under the18th constitutional amendment has been devolved leading to the transfer of powers to provincial governments. The Ministry of Health has a number of vertical public health programs such as Extended Program of Immunization, Family Planning & Primary Health Care, National Tuberculosis Control Program, National Aids Control Program, etc. which are funded by the federal gov- ernment but their implementation is carried out at the provincial and district levels. Table 44 gives an over- view of total public health facilities. Table 44: Public health facilities in Pakistan 2021 Type Number Beds Hospitals 1,289 127,225 Dispensaries 5,849 791 Basic Health Unit 5,561 6,767 Rural health centres 719
T.B. Clinic 410 154 Maternity & Child Welfare Centres (MCHCs) 752 319 Doctors 245,987
Dentists 27,360
Lady Health Workers 21,361
Midwives 43,129
Nurses 116,659
Source: Pakistan Statistical Year Book 2020
The health care provider which is a provincial subject is divided into primary, secondary and tertiary
health care:
Primary health care is implemented through Basic Health Units (BHUs), Rural Health Centers
(RHCs), Maternal and Child Health Centers (MCHCs) and Dispensaries.
Secondary health care includes first and second level referral facilities providing acute, ambulatory
and inpatient care through Tehsil Headquarter Hospitals (THQs), and District Headquarter
Hospitals (DHQs). Tehsil Headquarter Hospitals (THQs), and District Headquarter Hospi-
tals (DHQs) covers 100,000 to 300,000 and 1-2 million persons respectively the primary
and secondary health care constitutes the District Health System22.
22 Health System Profile – Pakistan, as cited above
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Tertiary health care is provided through major hospitals with s pecialized facilities which under the
administrative jurisdiction of provinces.
Annexure 3 describes the provincial system of health care in a scheme. Annexure 4 gives a sche-
matic overview of the overall health care system in Pakistan with public and private sector as its two main
components. The public sector can further be subdivided into federal government, provincial governments
and autonomous bodies of both of them. For the federal government Ministry of Health and Ministry of
Defense are the main stakeholders. The private sector is subdivided into five categories of health care
providers.
7.2 Military health care system, cantonment boards, autonomous bodies
The provision of medical services in military setup is the responsibility of the Army Medical Corps.
Their overall responsibilities include maintaining and promotion of health and prevention of diseases , pro-
vision of care and treatment to sick and wounded , rapid collection and speedy evacuation of casualties in
the field from Forward Defended Localities for life and limb saving surgery at Forward Treatment Centre /
Field Hospital/Base Hospital, supply and replenishment of medical equipment and stores and provision of
skilled and expert treatment in the base hospitals/centers of excellence. The population covered by military
health care system includes serving soldiers, families, parents, retired soldiers, civilians paid from defense
estimates and civilian non-entitled.
Annexure 5 categorizes the military health care system according to the services provided (pre-
ventive or curative) and to the groups of beneficiaries (military personnel exclusively or their dependents
also or even the general public at large). The perception that Fauji Foundation is the corporate face of Army
is not correct and in fact it is a private charitable trust. The Government of Pakistan, Ministry of Health,
Labour, Social Welfare and Family Planning, vide Notification No SR 395 (K) 72 dated 8 March 1972 reg-
istered a Scheme of Administration for Fauji Foundation under the Charitable Endowment Act 1890 thus
retaining its status as a private trust. It neither receives any subsidy from the government of Pakistan nor
gives any financial support to army23.
Military Lands & Cantonment Department is an attached department of Ministry of Defense. There
are 43 cantonment Boards in Pakistan. Geographically, 22 Cantonment Boards are in Punjab, 8 in Sindh,
9 in KP, and 4 in Baluchistan. They have hospitals/dispensaries pr oviding health care to their employees
as well as to the residents of the respective Cantonments. Each Cantonment Board has financial autonomy.
ABs/Cs are set up in the public sector under an act of legislation or ordinance (subject to legislative
approval) to perform regulatory, operational, corporate, promotional, research and developmental func-
tions. They may provide health services to their employees through following means:
• Health care through their own health facilities
• Provision of medical allowance to their employees
• Reimbursement of medical bills.
• Provision of health insurance to their employees.
23Fauji Foundation, Pakistan. Accessed at: http://www.fauji.org.pk/Webforms/Legal.aspx Date accessed: 17/11/2009 Pakistan Bureau of Statistics National Health Accounts
80
7.3 Social protection in Pakistan In common language as well as in many technical texts the terms “social protection”, “social assis- tance”, “social security” and “social insurance” often are mixed up. Figure 8 intends to give some clarification in this regard. Social protection is defined as “the set of policies and programs designed to reduce poverty and vulnerability by promoting efficient labor markets, diminishing people's exposure to risks, and enhanc- ing their capacity to protect themselves against hazards and interruption/loss of income 24”. In United Nations’ Classification of the Functions of Government (COFOG) social protection be- sides of health care covers sickness and disability, old age, survivors, unemployment and some other is- sues of social exclusion 25. Social protection has its two components social insurance and social assis- tance26. Social assistance can further be classified into private and governmental social assistance (see Figure 5). Figure 8: Overview of social protection in Pakistan
In Pakistan’s context, Zakat is one of the important forms of social assistance. In addition to Zakat there are other forms of social assistance in Pakistan such as social assistance in kind, welfare services etc. Zakat can further be broken down into governmental and private Zakat. In this context,
24Asian Development Bank. Social Protection, Official Policy Paper. July 2003. Available at: http://www.adb.org/documents/poli-
cies/social_protection/#contents. Accessed 15 January 2009
25 COFOG is available on website United Nations Statistics Department (UNSD)
26ADB, Social Protection Strategy Development Study, Social Protection, Final Report Vol. 1: Social Protection.
Social protection
Social assistance
Social insurance
Government
Private
Social
Security
Employment related
social insurance
other than social se-
curity
Group
Insurance
Other
Other
PBM
Zakat
Other
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social assistance and social insurance matter with regard to their fraction related to health expenditure, only. In this section, the primary focus would be on the social security and Zakat while the private health insurance (including employment related social insurance) would be dealt with in private sector, in section 8.5. 7.3.1 Employees social security institutions The risk of getting sick can be covered by private health insurance or by social insurance. Social insurance is not easy to define. According to the United Nations’ System of National Accounts 2009 (para. 17.84) a social insurance scheme is an insurance scheme where the following two conditions are satisfied: • the benefits received are conditional on participation in the scheme and constitute social benefits as this term is used in the SNA; and • at least one of the following three conditions is met:
- Participation in the scheme is obligatory either by law or under the terms and conditions of employment of an employee, or group of employees;
- The scheme is a collective one operated for benefit of a designated group of workers, whether employed or non -employed, participation being restricted to members of that group;
- An employer makes a contribution (actual or imputed) to the scheme on behalf of an employee, whether or not the employee also makes a contribution. Those participating in social insurance s chemes make social contributions to the schemes and receive social benefits. In Pakistan, a social insurance system exists in the form of social security since 1967, though it is very limited in scope and area. Social security in Pakistan offers a limited umbrella of social health protection, encompassing a selected segment of the population, which constitutes no t more than 5% of the total population. Employees Social Security Institutions (ESSI) are present in all four provinces and are provincial autonomous bodies attached to respective provincial Department of Labour. These institutions cover areas such as sickness, maternity, work injury, invalidity and , death benefits. However, their primary focus is on provision of medical care to the employees of private industries and commercial establishments employing 5 to 10 or more employees (depending upon the province). The coverage is provided to the employees of these establishments drawing monthly wages up to 5,000 -10,000 Rupees, depending upon the province27 (Figure 6). The workers and their dependents are entitled to medical care from the first day of the employ- ment. The dependents include wife, dependent parent and any unmarried children up to 21 years. Other categories of employees, such as day l abors and agricultural workers (Informal Sector) are excluded yet. For providing medical care to the secured workers, the provincial social security institutions have a network of hospitals, dispensaries, treatment centers; qualified doctors, paramedical staff, ambulances etc.
27 Naushin Mahmood, Zafar Mubeen, Pension and Social Security Schemes in Pakistan: Some Policy Options. PIDE Working Paper, 2008:42.
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These services are provided free to the employees as their employer pays these contributions.
Employers covered under the scheme contribute towards the scheme at the rate of 7% of their wages paid
to insurable workers. The secured em ployees incur no deduction, co -payment, or any other cost in order
to avail these services. They can avail these services after proper registration from the department and
after qualifying a period of 3 months.
Figure 9: Social security system in Pakistan
Adapted from: Health System Profile – Pakistan. Regional Health System Observatory-EMRO, World Health Organization, 2007
7.3.2 Zakat managed by government Zakat system in Pakistan can be divided generally into two major components 28 namely private Zakat (which is included in the philanthropic section 7.6) and governmental Zakat. The governmental sys- tem was introduced through “Zakat and Ushr Ordinance 198029”. The benefits are targeted at the poorest. The main systems providing social assistance benefits are Zakat and Bait -ul-Mal30. Zakat fund is utilized for assistance to the needy, the indigent and the poor particularly orphans and widows, the handicapped , and the disabled.
28ADB, Social Protection Strategy Development Study, Social Protection, Final Report Vol. 1: Social Protection, 34ff.
29Zakat & Ushr Ordinance, 1980, (NO.VIII of 1980).
30 ADB, as cited above, 34ff.
Source
Private commercial
establishments
employing 10 or
more employees
Agents
Employee’s social security
institutions
Provider
Health facilities
Which include
dispensaries,
medical centres
and hospitals
Reimbursements
(For treatments not available at social security institutions)
Provision of services
Social security
contribution from the em-
ployer
Employers covered under
the scheme contribute
towards the Scheme @ 7%
of wages paid to insurable
workers. The insurable
workers are those drawing
up wages between 5,000 –
10,000 Rs (depending upon
the province)
Beneficiaries Workers secured under the social security scheme Pakistan Bureau of Statistics National Health Accounts
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The system relies on mandatory Zakat deduction at the rate of 2.5% from the value of following 11 categories of assets: ▪ Saving bank accounts ▪ Notice deposit receipts and accounts ▪ Fixed deposit receipts and accounts (e.g., Khas Deposit Certificate) ▪ Saving/deposit certificates (e.g., Defence Saving Certificates, National Deposit Certifi- cates) ▪ Units of the National Investment Trust ▪ ICP Mutual Fund Certificates ▪ Government Securities (other than prize bonds) ▪ Securities including shares and debentures ▪ Annuities ▪ Life insurance policies ▪ Provident funds
7.3.3 Pakistan Bait-ul-Mal
Pakistan Bait-ul-Mal (PBM), an autonomous body set up through an Act in 1991 works under the
umbrella of Ministry of Social Welfare and Special Education. PBM is significantly contributing toward pov-
erty alleviation through its various services focused on the poorest of the poor and providing assistance to
destitute, widow, orphan, invalid, infirm & other needy persons, as per eligibly criteria approved by Bait-ul-
Mal Board. They also spend money on health in various forms:
•
Through Individual Financial Assistance (IFA) the poor, widows, destitute women, orphans
and disabled persons are supported through general assistance, education, medical treatment
and rehabilitation. The financial assistance for health is dedicated for the medical treatment of
major ailments and disabilities of the poor patients. The financial ceiling for medical treatment
is 300,000 Rs.
•
The regular portion of Bait-ul-Mal’s money, dedicated for health, is the IFA for medical treat-
ment. In addition, it has supported (not as a regular activity) in the past the establishment of
the new health care facilities. For instance, it has supported the opening of a drug and diag-
nostic center in KP and also supported the construction of a burn and reconstructive surgery
center in Lahore.
•
PBM also has a project named Institutional Rehabilitation which basically provides support to
registered NGOs under following three strategies
o
Strategy-I: Institutional support for the poor: Sharing the capital cost by Pakistan Bait
ul Mal (PBM) at the ratio 50% and 50% share of NGO.
o
Strategy-II: Free eye care for cataract operations: Technical committee assists PBM
in selecting suitable NGOs. Actual expenses of cataract operations provided on an-
nual/quarterly basis
o
Strategy-III: Innovative Pilot Project; PBM-NGO’s partnership for 3 to 5 years. Sharing
capital cost and recurring expenses 50% NGO