Public Health and Health System's Responsiveness During the 2022 Floods in Pakistan: What Needs to Be Done?

OBJECTIVE: In 2022, Pakistan witnessed unprecedented flooding, submerging one-third of the country under-water, ruining millions of houses, taking lives, afflicted injuries, and displacing scores of people. Our study documents not only the public health problems that have arisen due to this natural calamity but also the state of health systems' response. METHODS: We conducted a qualitative study asking key questions around prevalent health problems, health-care seeking, government's response, resource mobilization, and roadmap for the future. We purposively selected 16 key frontline health workers for in-depth interviews. RESULTS: Waterborne and infectious diseases were rampant posing huge public health challenges. Disaster mitigation efforts and relief operations were delayed and not at scale to cover the entire affected population. Moreover, a weak economy, poverty, and insufficient livelihoods compounded the tribulations of floods. Issues of leadership and governance at state level resulted in disorganized efforts and response. CONCLUSIONS: Pakistan is famous for its philanthropy; however, lack of transparency and accountability, the actual benefits seldom reach the beneficiaries. Such climatic disasters necessitate a more holistic approach and a greater responsiveness of the health system. In addition to health services, the state must respond to financial, social, and infrastructural needs of the people suffering from the calamity.

Universal health coverage in Pakistan: is the health system geared up to take on the challenge?

BACKGROUND: There is a strong and wide consensus that Pakistan must pursue universal health coverage (UHC) attainment as the driving force for achieving sustainable development goals by 2030. Nevertheless, several institutional and socioeconomic challenges may hinder the progress toward UHC. MAIN BODY: It is important that the health system of Pakistan must be transformed to strengthen all three dimensions of UHC i.e. maximizing the population covered, increasing the range of services offered, and reducing the cost-sharing. To make UHC dream a reality in Pakistan, there are some pre-requisites to meet upfront: a) budgetary allocation for health as percentage of GDP must be increased; b) health system's readiness especially in the public sector ought to improve in terms of human resource and availability of essential services; c) safety nets for health must continue regardless of the change in the political regimes; d) decrease the reliance on donors' funding; and e) accountability to be ensured across the board for service providers, managers, administrators and policymakers in the health system. CONCLUSION: COVID-19 pandemic has revealed some major gaps in the health system's capacity to deliver equitable healthcare, which is a cornerstone to achieving the UHC agenda. The priority-setting process will need to be aligned with the SDGs to ensure that the agenda for action towards 2030 is comprehensively addressed and successfully accomplished preferably before, but hopefully not beyond the targeted dates.

Out Of Pocket Expenditure On Thalassemia Major And Its Implications On The Household Economics.

BACKGROUND: Pakistan faces a considerable burden of disease with regard to inherited blood disorder, i.e., Thalassemia Major. Its economic implications are least studied before, particularly when it comes to ascertaining a household's out of pocket expense on treating the disease. This study was carried out to understand the current estimate of Out-of-pocket expenditure (OOP) expense and its implications on the household and livelihood, while seeking treatment for a child suffering from thalassemia. Methods: It was a descriptive cross-sectional study of 3 months' duration. Patients were selected from Fauji Foundation Hospital (FFH) and Pakistan Institute of Medical Sciences (PIMS), through. The descriptive quantitative analysis and inferential analysis was carried through purposive sampling. RESULTS: Treatment expense of entitled patients from FFH hospital (a public hospital which offers entitlement to the families of retired army personnel) was compared with that of non-entitled patients coming to PIMS (a public sector general hospital). Total expense incurred on treatment by the end of the month was PKR. 5000-10,000 (USD31-62) in FFH, while at PIMS, the total expense incurred on treatment by the end of the month was around PKR 80,000 (USD500). Around 37% families having an average monthly income of PkRs25000 (USD150) only, sold their livelihoods, 31% compromised on their children's education expenses and 23% percent curtailed the health expenses of the other children. CONCLUSIONS: The out-of-pocket expenditure on treating TM is quite high and compels the families to borrow money and sell or mortgage their property, which puts a great deal monetary pressure given their socio-economic status. A practical solution would be to cover these families under the health safety net supported by the government.

Pakistan's Health and Population Think Tank: a policy platform for achieving Sustainable Development Goal 3 national targets.

In Pakistan, the Health and Population Think Tank was launched as an initiative to conduct programmes and policy analysis, as well as give an insight into the possible future policy options on various national health issues relevant to all the provinces. This forum has also served as a platform to discuss how provincial strategies could be aligned with the National Health Vision 2016-2025, which was developed with the consensus of all provinces and development partners. Main topics chosen for the round tables included local production of vaccines; social health protection; quality of care at the time of birth; human resources for health; and the challenge of tuberculosis in Pakistan. Policy briefs produced by the think tank will maximize the absorption of knowledge and will help implement the actionable items needed to speed up the progress towards achieving Sustainable Development Goal 3 (SDG3) national targets.

Capacity building on health diplomacy: a training experience from Pakistan.

Modern-day globalization means that many health issues cannot be resolved by the affected country alone, and this necessitates political consultations, diplomatic negotiations and cross-border solutions. A few examples that require health diplomacy efforts are: halting resentment towards immunization, addressing the burden of noncommunicable diseases, enabling access to drugs and technology, and liberalizing trade to reduce the cost of drugs. The agenda of Sustainable Development Goals (SDGs) demands a concerted effort to achieve the ambitious targets. This article reports the experience of health diplomacy training imparted to mid-level and senior officials in the public as well as private sector in Pakistan. Training was geared to inculcate an understanding of global health diplomacy and governance, and to develop an appreciation of the relationship of global health with other disciplines such as foreign affairs, economics, trade, climate change and human rights. Participants included health professionals, experts from departments other than health, government officials and diplomats. This training was expected to enhance their knowledge of health systems dynamics that are influenced by foreign policy and diplomatic discourses.

Community based saving groups: an innovative approach to overcome the financial and social barriers in health care seeking by the women in the rural remote communities of Pakistan.

BACKGROUND: In remote rural areas of Pakistan, access to the maternal, newborn and child health (MNCH) care provided by a skilled health provider is quite difficult. There are many reasons such as women's restricted social mobility, lack of education, disenfranchised in decision making and poverty. To overcome these barriers and impediments in district Chitral, which is the largest territory in terms of geography in province Khyber Pakhtunkhwa, local women of reproductive age, were mobilized to form the Community Based Saving Groups (CBSGs) at the village level. In these CBSGs, they pool-in their money, and then provide soft loans to the expecting mothers to meet the expenses of delivery. Simultaneously, young literate women were identified from the local communities; they were trained as Community Midwives (CMWs), using national MNCH curriculum, and later deployed in their respective villages within the district. This study captured their perceptions about the formation of CBSGs to overcome the financial and social barriers, and subsequent use of CMW services. METHODS: A qualitative enquiry was conducted with the delivered mothers and their husbands through gender specific separate focus group discussions, with CBSG members and with non-members in four different sites of District Chitral. RESULTS: CBSG member women were far more aware on health issues. Information sought from these forums brought a noticeable change in the health seeking practices. Seeking care from a trained birth attendant in the community became easier. Women associated with the CBSGs as members, expressed an increased access to money for utilizing the CMW services, better awareness on MNCH issues, and empowerment to decide for seeking care. CBSG have been an instrumental platform for social networking, helping each other in other household matters. CONCLUSION: Women have started using the services of CMW and the CBSGs have actually helped them overcome the financial barriers in health care seeking. Moreover, the CBSGs became a medium to improve the awareness of service availability, understanding the MNCH issues, and timely utilization of MNCH services.

Role of development partners in Maternal, Newborn and Child Health (MNCH) programming in post-reform times: a qualitative study from Pakistan.

OBJECTIVES: Despite certain reforms undertaken in Pakistan to reorient its health system, the health-related millennium goals lagged behind many neighbouring and regional countries. This study was conducted to understand the implications of government reforms including the devolution on the National Maternal Newborn and Child Health (MNCH) programme; and to determine donors' and development partners' current and prospective role in the post-reform scenario. SETTING: The donor agencies based in the federal capital Islamabad, as well as the federal and provincial government offices involved in the financing, design, oversight and implementation of various MNCH initiatives in Pakistan, were included in the sample. PARTICIPANTS: A descriptive qualitative study based on individual in-depth interviews with representatives from donor agencies and government offices (8 each) involved in programmes directly related to the MNCH sector. RESULTS: The reforms are denounced as deficient in terms of detailed planning and operationalisation of the vertical programmes including that for MNCH. The government had to face coordination challenges with the provinces, which has affected donor engagement and funding mechanisms to a great deal. Investment in MNCH, population and nutrition has been the topmost priority of development partners in Pakistan. Their contributions towards health systems also include assistance in developing and implementing provincial health sector strategies, establishment of Health Sector Reform Units and investments in service delivery, research and advocacy. CONCLUSIONS: Any health sector reform must be complemented by a roll-out strategy, including robust support to the provincial health systems and to their capacity building. Development partners must align and coordinate their strategies with provinces to stabilise the MNCH programme in Pakistan. More coordination between the different tiers of the government and the donors could streamline MNCH partnership in post-reform times.

Low utilization of postnatal care: searching the window of opportunity to save mothers and newborns lives in Islamabad capital territory, Pakistan.

BACKGROUND: Each year an estimated 289,000 maternal deaths occur worldwide; of which 50 % of maternal deaths occur around labor, delivery and immediate postpartum period. Postnatal care (PNC) is crucial but relatively neglected component in the continuum of care, and hence a missing link toward safe motherhood. Despite the significant improvement in child health and safe motherhood interventions, maternal mortality ratio, perinatal mortality and neonatal mortality still remain a challenge in achieving the Millennium Development Goals 4 and 5 in Pakistan. METHODS: This was a descriptive cross sectional study carried out in the four union councils of Islamabad capital territory, to understand the determinants of postnatal health care seeking. The study sample comprised 225 postpartum women with a child 0 to 1 month of age, and the health care providers from both public and private sector. A pre-tested semi-structured questionnaire was used for data collection. One focus group discussion with health care providers was conducted, using open ended questions guide. RESULTS: Only 30 % women received PNC; amongst which 68 % went to a government health facility. According to the health service providers, 90 % women are not interested in PNC, and that is because they lack awareness, face mobility and transportation issues, and cannot afford the cost of health care. Besides many other determinants, women's education was significantly associated with the PNC utilization. CONCLUSION: More robust and culturally sensitive campaign on importance of PNC must be thought out by the national MNCH program to inform the less literate and peri urban inhabitants of Islamabad. Health providers ought to be sensitized and trained for promoting PNC to save maternal and newborn lives.

EXPERIENCE OF VOUCHERS FOR REPRODUCTIVE HEALTH SERVICES IN DEVELOPING COUNTRIES: MAKING A CASE FOR PAKISTAN THROUGH A SYSTEMATIC REVIEW.

Among the healthcare financing techniques that exist, output-based financing or vouchers is a strategy that is growing in popularity. There is a need of an in-depth analysis of the impacts of vouchers on health indicators, particularly for Pakistan. Assessment of the existing evidence on how much the vouchers impact on health and healthcare utilization can be of greater value to the policy makers for informed decision making. This systematic review included 16 cross-sectional and quasi-experimental design studies. Service utilization, knowledge, service quality, cost-effectiveness of the programme and outreach of the population served were observed as outcomes. We found positive results in with regard to most of these outcomes. Physical accessibility, social mobility of women, security threats, and sustainability of the project after donor exit appear as serious challenges. Yet, lessons can be drawn for the scaling up of the reproductive health services in the country, through the use of vouchers.

'Only systems thinking can improve family planning program in Pakistan': A descriptive qualitative study.

BACKGROUND: Family Planning (FP) program in Pakistan has been struggling to achieve the desired indicators. Despite a well-timed initiation of the program in late 50s, fertility decline has been sparingly slow. As a result, rapid population growth is impeding economic development in the country. A high population growth rate, the current fertility rate, a stagnant contraceptive prevalence rate and high unmet need remain challenging targets for population policies and FP programs. To accelerate the pace of FP programs and targets concerned, it is imperative to develop and adopt a holistic approach and strategy for plugging the gaps in various components of the health system: service delivery, information systems, drugs-supplies, technology and logistics, Human Resources (HRs), financing, and governance. Hence, World Health Organization (WHO) health systems building blocks present a practical framework for overall health system strengthening. METHODS: This descriptive qualitative study, through 23 in-depth interviews, explored the factors related to the health system, and those responsible for a disappointing FP program in Pakistan. Provincial representatives from Population Welfare and Health departments, donor agencies and non-governmental organizations involved with FP programs were included in the study to document the perspective of all stakeholders. Content analysis was done manually to generate nodes, sub-nodes and themes. RESULTS: Performance of FP programs is not satisfactory as shown by the indicators, and these programs have not been able to deliver the desired outcomes. Interviewees agreed that inadequate prioritization given to the FP program by successive governments has led to this situation. There are issues with all health system areas, including governance, strategies, funding, financial management, service delivery systems, HRs, technology and logistic systems, and Management Information System (MIS); these have encumbered the pace of success of the program. All stakeholders need to join hands to complement efforts and to capitalize on each other's strengths, plugging the gaps in all the components of FP programming. CONCLUSION: All WHO health system building blocks are interrelated and need to be strengthened, if the demographic targets are to be achieved. With this approach, the health system shall be capable of delivering fair and responsive FP services.

A case study of outsourced primary healthcare services in Sindh, Pakistan: is this a real reform?

BACKGROUND: Since a decade, low and middle income countries have a rising trend of contracting their primary healthcare services to NGOs. In Pakistan, public sector often lacks capacity to effectively & equitably manage the healthcare services. It led the government to outsource the administration of primary health care services to a semi-autonomous government entity i.e. Peoples' Primary Healthcare Initiative (PPHI). This small scale study has assessed the quality of healthcare services at the contracted Basic Health Units (BHUs) with the PPHI and compared it with those managed by the local district government in the province of Sindh. METHODS: A cross-sectional mix methods survey was conducted in November 2011. Two BHUs of each type were selected from the districts Karachi and Thatta in Sindh province. BHUs were selected randomly and a purposive sampling technique was used to recruit the study participants at the two study sites. Focus group discussions were conducted with patients visiting the facility while in-depth interviews were conducted with service providers. An observation based resource availability checklist was also administered. RESULTS: There was a significant difference between the PPHI and the district government administered BHUs with regard to infrastructure, availability of essential medicines, basic medical appliances, mini-lab facilities and vehicles for referrals. These BHUs were found to have sufficient number of trained clinical staff and no punctuality and retention issues whatsoever. The district government administered BHUs presented a dismal picture in all the aspects. CONCLUSION: Out-sourcing of primary healthcare facilities has resulted in significantly improved certain aspects quality and responsiveness of primary healthcare services. This strategy is likely to achieve an efficient and perhaps an equitable healthcare delivery in low and middle income countries where governments have limited capacity to manage healthcare services.

Health care seeking patterns and out of pocket payments for children under five years of age living in Katchi Abadis (slums), in Islamabad, Pakistan.

BACKGROUND: Since 1990, Pakistan has faced an unprecedented rate of urbanization, thereby resulting in the uncontrolled proliferation of slums (Katchi Abadis) in all large cities. These areas lack the basic municipal services such as safe water supply, sanitation and waste collection. There is limited access to quality health care services, both curative and preventive. Therefore, communities living in katchi abadis are faced with health seeking challenges and catastrophic expenditure to pay for health care services (formal or informal). METHODS: This cross-sectional quantitative study was conducted in Islamabad, using a semi-structured questionnaire with mothers of children 5 years of age. There are 34 katchi abadis, 11 are recognized by the Capital Development Authority, out of which seven were included in the study. The calculated sample size was 207. MAIN FINDINGS: Average household income was found to be Pak Rupee 10,000 (approx.US$100) per month. Diarrhea, fever, common cold and cough were common illnesses among under 5 children. Approximately 43% of the mothers were illiterate and they preferred consulting a private doctor or a private dispenser in the katchi abadi. Mother's level of education was significantly associated with the type of health provider consulted. Majority had to spend out of pocket, while many either borrowed money from relatives or friends or sold a household item. Delay in seeking health care added to the out of pocket expense. The mean cost on child's treatment was approximately PkRs400 (approximately US$ 4) for a single consultation. CONCLUSION: There are several factors associated with health seeking behavior of mothers of children under the age of 5 years, living in the katchi abadis of Islamabad. The latter population group is one of the most vulnerable given their poor standard of living conditions. A multi-sectoral approach is needed to address the provision of basic amenities, the availability of safety nets to pay for health care is crucial to avoid catastrophic expenditure and the provision of community-based health promotion programs are essential to improve health seeking behaviors whilst simultaneously promoting and protecting health.

Sustaining the stride of health agenda beyond 2015 in post mdgs scenario: a projected roadmap for the developing countries.

As the world is reaching toward 2015, the echoes of MDGs are becoming louder. Results with regard to achievements of the targets set globally, show mixed results. Very understandably, the developing countries will miss most of the targets by far, and the attributed reasons are obvious. Dearth of resources-financial and human, evidence for decision making, infrastructure, meaningful collaboration with developed countries, and overall governance of the health sector are some of the pitfalls on 2000-2015 screen. Nonetheless, international commitments are sending positive vibes and message that glass is half full. Countries must keep the pace and sustain the stride of MDGs agenda, with an appraised roadmap, of course. Poverty, natural and man-made disasters, and slow socio-economic development, and some incongruous technologies are the challenges en route. A holistic approach is the need of the time, and therefore this paper presents a strategic framework drawn from the WHO's proposed health systems building blocks, which might, help the developing countries and fragile health systems to turn around the state of affairs.

National program for family planning and primary health care Pakistan: a SWOT analysis.

BACKGROUND: The National Program for Family Planning and Primary Healthcare was launched in 1994. It is one of the largest community based programs in the world, providing primary healthcare services to about 80 million people, most of which is rural poor. The program has been instrumental in improving health related indicators of maternal and child health in the last two decades. METHODS: SWOT analysis was used by making recourse to the structure and dynamics of the program as well as searching the literature. SWOT ANALYSIS: Strengths of the program include: comprehensive design of planning, implementation and supervision mechanisms aided by an MIS, selection and recruitments processes and evidence created through improving health impact indicators. Weaknesses identified are slow progress, poor integration of the program with health services at local levels including MIS, and de-motivational factors such as job insecurity and non-payment of salaries in time. Opportunities include further widening the coverage of services, its potential contribution to health system research, and its use in areas other than health like women empowerment and poverty alleviation. Threats the program may face are: political interference, lack of funds, social threats and implications for professional malpractices. CONCLUSION: Strengthening of the program will necessitate a strong political commitment, sustained funding and a just remuneration to this bare foot doctor of Pakistan, the Lady Health Worker.

Impact of social franchising on contraceptive use when complemented by vouchers: a quasi-experimental study in rural Pakistan.

BACKGROUND: Pakistan has had a low contraceptive prevalence rate for the last two decades; with preference for natural birth spacing methods and condoms. Family planning services offered by the public sector have never fulfilled the demand for contraception, particularly in rural areas. In the private sector, cost is a major constraint. In 2008, Marie Stopes Society - a local NGO started a social franchise programme along with a free voucher scheme to promote uptake of IUCDs amongst the poor. This paper evaluates the effectiveness of this approach, which is designed to increase modern long term contraceptive awareness and use in rural areas of Pakistan. METHODOLOGY: We used a quasi-experimental study design with controls, selecting one intervention district and one control district from the Sindh and Punjab provinces. In each district, we chose a total of four service providers. A baseline survey was carried out among 4,992 married women of reproductive age (MWRA) in February 2009. Eighteen months after the start of intervention, an independent endline survey was conducted among 4,003 women. We used multilevel logistic regression for analysis using Stata 11. RESULTS: Social franchising used alongside free vouchers for long term contraceptive choices significantly increased the awareness of modern contraception. Awareness increased by 5% in the intervention district. Similarly, the ever use of modern contraceptive increased by 28.5%, and the overall contraceptive prevalence rate increased by 19.6%. A significant change (11.1%) was recorded in the uptake of IUCDs, which were being promoted with vouchers. CONCLUSION: Family planning franchise model promotes awareness and uptake of contraceptives. Moreover, supplemented with vouchers, it may enhance the use of IUCDs, which have a significant cost attached. Our research also supports a multi-pronged approach- generating demand through counselling, overcoming financial constraints by offering vouchers, training, accreditation and branding of the service providers, and ensuring uninterrupted contraceptive supplies.

Resource allocation in Pakistan's health sector: a critical appraisal and a path toward the Millennium Development Goals.

Pakistan is trying hard to sustain its progress toward the Millennium Development Goals. However, because of a lack of political commitment to innovative solutions to improve its financing mechanism, the health system is unable to provide even essential and basic services to the people. The country, with more than 70% of the population living on less than two US dollars a day, largely depends on direct taxes for its revenue. Because of inadequate financing, the quality of government services is inexcusably poor; therefore, a majority of people seek healthcare in the private sector. This has led to a horde of issues pertaining to equity, accessibility and fairness. High out-of-pocket expenses on health jeopardize a family's livelihood, pushing it into a vicious circle of poverty. In the wake of recent devolution, this paper presents options for future health financing that enables the provinces to exert their autonomy to safeguard the health of the most vulnerable in the country. Our recommendations follow the vision of the World Health Organization and the Commission on Macroeconomics and Health, to achieve universal health coverage and social protection for the poor.

Family planning and contraception in Islamic countries: a critical review of the literature.

INTRODUCTION: The population of the world reached seven billion in 2012. Pakistan's population stands at more than 180 million, is growing rapidly, and has the highest unmet need for family planning (FP) in isolated rural areas. The low usage of contraception in the rural areas of Pakistan correlates with the level of isolation, poverty, illiteracy, and to a large extent, religious misinterpretations/misconceptions. Almost 25% of couples who desired FP services were not receiving them for a variety of reasons of which religion could be one, especially in the rural remote areas where the media is still not reaching and influencing mind-sets. In this scenario, the role of social marketing in bringing about attitudinal and behavioural change among users in underserved areas and gatekeepers and opinion makers in society must not be neglected. The work in promoting FP, contraception and birth spacing requires authentic evidence from similar sociocultural contexts and this endeavour of compiling case studies from various Islamic countries on their FP initiatives is a good step. Governments around the world, including many in the Islamic world, support FP programmes to enable individuals and couples to choose the number and timing of their children. METHODS: This paper is a review of secondary data accessed through PubMed and Google Scholar. It provides an overview of Islamic countries' policies on, and support for FP and modern contraception. For this purpose, literature from Afghanistan, Bangladesh, Egypt, Indonesia, Iran, Jordan, Kuwait, Malaysia, Morocco, Nigeria, Pakistan, and Turkey was included. RESULTS: There are significant internal social and economic reasons to focus on FP in the Muslim world. Thus, arguments by religious scholars who see FP as an external western conspiracy aimed at curtailing the growth and strength of the Islamic world appear to be uninformed of both the socio-political and demographic realities in many Muslim countries, as well as the historical permissibility of contraception within the Islamic legacy. In fact, it can be argued that given the profound socio-economic and political difficulties in various parts of the Muslim world, a lack of FP and increasing populations would weaken and curtail the pace of overall development. CONCLUSION: Private institutions and the government must collaborate in leveraging initiatives and bridging gaps for more robust advocacy with clergymen and religious scholars to support the larger cause of FP and birth spacing i.e. improving infant and maternal health in Pakistan.

Emergency obstetrics care services in District Neelum, Azad Jammu and Kashmir.

BACKGROUND: Globally 529,000 women die annually due to pregnancy related problems and in Pakistan alone this toll is about 35,000 deaths per annum. This situation is even more critical in the rural remote areas of Azad Jammu & Kashmir (AJK). The whole phenomenon needs a contextual assessment to ascertain the geographical, financial and socio culturaI accessibility, and availability of EmOC services in order to generate fresh evidence for the decision makers and concerned stakeholders for improving these services. METHODS: A cross-sectional study was conducted using a structured questionnaire with the women delivered in the last 15 days, whereas the geographical accessibility and availability of EmOC services were assessed by visiting EmOC facilities in the district Neelum of AJK. RESULTS: Over a hundred women delivered in the last 15 days, participated in the study. Geographically, a central EmOC facility is far away and the terrain is hilly and dangerous. Women's social status, education, husband's employment and household income were found to have a significant association with the use of EmOC services. The health facilities audit showed that around 90% centres do not have a female medical officer appointed. Moreover, the state of the equipment, medicines and the basic utilities such as water, sanitation, and electricity are not satisfactory. CONCLUSION: Accessibility of EmOC services is poor in the district Neelum. Evidence on ground calls for organisational reforms at EmOC service delivery level as well as for long term planning in other sectors for improving socioeconomic and education status of the women in Azad Jammu & Kashmir.

Reforms in Pakistan: decisive times for improving maternal and child health.

Pakistan is a struggling economy with poor maternal and child health indicators that have affected attainment of the United Nations Millennium Development Goals 4 and 5 (under-five child and maternal mortality). Recent health reforms have abolished the federal Ministry of Health and devolved administrative and financial powers to the provinces. Ideally, devolution tends to simplify a healthcare system's management structure and ensure more efficient delivery of health services to underserved populations, in this case women and children. In this time of transition, it is appropriate to outline prerequisites for the efficient management of maternal and child health (MCH) services. This paper examines the six building blocks of health systems in order to improve the utilization of MCH services in rural Pakistan. The targeted outcomes of recent reforms are devolved participatory decision-making regarding distribution of MCH-related services, improved deployment of the healthcare workforce, prioritization of pro-poor strategies for health financing and integration of various health information systems. Given this window of opportunity, the provinces need to guarantee fairness and equity through their stewardship of the healthcare system so as to protect vulnerable mothers and their children, especially in rural, remote and disadvantaged areas of Pakistan.

Social protection strategies and health financing to safeguard reproductive health for the poor: making a case for Pakistan.

Globally, a billion people cannot seek appropriate and timely healthcare because they are not covered under any social protection and health insurance system. Countries where government financing for health care is meagre, the situation is even worse. Pakistan with its slowly improving indicators of maternal and child health makes a classical case for instigating a social protection mechanism for the poor segments of population. The Government safety nets are unable to cater the large proportion of poor population. NGOs partially cover the rural areas where majority of the vulnerable population lives but need to expand their scope of work. Donors have presented variety of models and frameworks which were seldom considered in the concerned quarters. All stakeholders ought to strategise their plans to adopt and scale up the successful interventions (vouchers, cash transfers, micro-credits, community based insurance etc) which have been operating but on a very small scale or for other types of health services, but none for reproductive health care per se. Adoption of risk pooling mechanisms and provision of accessible and quality reproductive health services seems feasible through a meaningful and integrated public private partnership in the times to come.