Mohammad Wasay  ( Department of Medicine and Community Health Sciences, Aga Khan University, Karachi, Pakistan )
Muhammad Ashar Malik  ( Department of Medicine and Community Health Sciences, Aga Khan University, Karachi, Pakistan )

Health care in Pakistan is financed and provided by public, philanthropy and private sectors. Current health care delivery systems largely provide tertiary care with very little focus on prevention. All three systems are working in Silos without a master plan. This practice has translated into uneven and unbalanced distribution of services. There is no communication, discussion, coordination and priority setting among these stake holders. After devolution, federal health contribution is limited to a vision document and none of provincial health ministries have a health policy document defining their priorities and aspirations. The public sector health delivery system comprises a district based health system developed on the principles of primary healthcare. This whole setup constitutes 13562 health facilities. Private sector provides healthcare to over 60%, while 30% constitute public sector of the healthcare delivery in the country. The remaining 10% are other types of provider including local NGOs and philanthropy. The share of private sector in total health expenditure is 65%, Philanthropy sector is 20% and public sector share is 15%. Public sector includes healthcare provided by the social security institutions and by the state and parastatal organization. Almost 90% of private health expenditure is household out-of-pocket payment.¹ While structurally, the public sector health facilities seem comprehensive to cater the health care needs of the population. Yet due to shortage of essential inputs, provision of health services is compromised. To fill up this gap, the private and philanthropy sectors have emerged as a parallel and overlapping health services provider especially in the last two decades. Establishment of health facilities in public sector carries some stringent criteria such as a basic health unit for a union council (smallest administrative unit)/ 5000- 10000 population and district hospitals with at least 8-10 specialties within each district². On the other hand, the private sector has expanded haphazardly following market principles of profit making and cost savings. Most of the tertiary care is concentrated in ten large cities of the country including national and provincial capital cities. This leaves rural and remote areas unserved and unattended for their relevant healthcare needs ³. The existing private provision of healthcare suffers from three challenges relating to access and delivery of healthcare. Firstly, private provision is overlapping with the public facilities. Many private facilities are operating next to public facilitates. This problem is severe at the locations of large tertiary care public hospitals that are engulfed by private clinics and diagnostic centers. Secondly private facilities are concentrating in large urban centers and even concentrating in specific areas of the cities. There are streets and avenues known as healthcare markets in the country such as Dabgrai Garden in Peshawar and Saidpur Road in Rawalpindi.Thirdly, private sector is highly focused on specialized Tertiary care services with high revenue potential. Philanthropy sector is versatile largely catering needs and aspirations of local and international donors. This sector has grown fast in last two decades and is likely to surpass public sector in terms of facilities and funding in near future. Such haphazard expansion of the private sectors is promoting unethical practices and unhealthy competition. Besides this aspect current private investment patterns are discouraging health human resource to explore opportunities of practicing medicine in areas where it direly needs such as rural and far-flung area of the country. Primary healthcare is the worst affected area of services delivery tiers. Without an effective referral system, tertiary care is overburdened and consuming over 80% of the resource of public sector alone. Recently provincial governments have legislated public and private sector regulations namely the health commissions in Punjab, Sindh and KPK provinces. Most of their functions relate to registration of medical providers, overseeing practice of medicine, implementing quality of care and curb malpractices and quackery. The real challenge of to access and delivery  of health services is awaiting the attention of the health policy makers and planners of the country. For the purpose of reaching out to the most deserving areas and a need based approach we recommend an integration of public, private and philanthropy sector investment in healthcare.^4,5 We propose following steps for an integrated health system to improve its efficiency and equity.

• A health need assessment analysis and area variation in the healthcare needs.
• A GIS mapping of all types of health facilitiesto identify services deficient areas.
• A Legislation to regulate private sector investment including a need based criteria for private investment in health sector.
• A mechanism to discourage further investments in tertiary care/teaching hospitals in private/public sector in ten big cities.
• Integration of health care delivery among private, philanthropy and public sector.
• National health vision and provincial health policy documents with integration of health services into a new model with higher priority of preventive health. While the pathway to an integrated health system is long but these steps can potentially promote geographical equity in health services provision.

Disclaimer: None to declare.
Conflict of Interest:None to declare.
Source of Funding:None to declare.

References

1. Pakistan Bureau of Statistics. National Health Accounts of Pakistan 2015-16 [Internet]. Islamabad: Government of Pakistan; 2016 [accessed 2017 Jun 29]. Available from: h t t p : / / w w w . p b s . g o v . p k / s i t e s / d e f a u l t / f i l e s / / N H A - Pakistan%202015-16%20Report_0.pdf.
2. Malik MA, Gul W, Abrejo F. Cost of primary health care in Pakistan. J Ayub Med Coll Abbottabad. 2015;27:88.
3 Zaidi SA. The urban bias in health facilities in Pakistan. Social Science & Medicine. 1985 ;20:473-82.
4. Hellowell M. The role of public-private partnerships in health systems is getting stronger. Commonwealth Health Partnerships. 2012:72.
5. Malik MA, Wasay M. Economics of health and health care in Pakistan. J Pak Med Assoc.2013;63:814-5.