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Used with the permission of Ratana21 / Shutterstock. Further permission required for reuse. Cover design: Shehryar Khan & Aqib Khilji / Blimp Digital Marketing & PR. Contents Acknowledgements����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� ix Abbreviations���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� x Executive Summary��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� xii 1. INTRODUCTION��������������������������������������������������������������������������������������������������������������������������������������������������������� 1 1.1.. Justification for health security�������������������������������������������������������������������������������������������������������������������������������������������������������������������� 3 1.2..Objective of the HFSA��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 3 1.3..Organization of the report�������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 4 2. METHODOLOGY��������������������������������������������������������������������������������������������������������������������������������������������������������� 5 2.1..Desk review���������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 6 2.2..The sample������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������ 6 2.3..The approach�������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 7 2.4..Data collection����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 8 2.5..Limitations and challenges��������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 9 3. RESULTS����������������������������������������������������������������������������������������������������������������������������������������������������������������������11 3.1.. Funding for specific health security areas������������������������������������������������������������������������������������������������������������������������������������������������ 12 3.2..Health security activities in Pakistan��������������������������������������������������������������������������������������������������������������������������������������������������������� 28 3.3..Stakeholder mapping����������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 41 3.4.. Overview of the macrofiscal context������������������������������������������������������������������������������������������������������������������������������������������������������� 48 3.5..Financing for health security budgeting and resource allocation��������������������������������������������������������������������������������������������������������� 56 3.6.. Resource mobilization—review of health financing in Pakistan��������������������������������������������������������������������������������������������������������� 61 3.7..Constraints and limitations of the current planning and budgeting processes��������������������������������������������������������������������������������� 65 4. FINDINGS AND RECOMMENDATIONS�������������������������������������������������������������������������������������������������������� 69 4.1..Findings��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 70 4.2..Recommendations��������������������������������������������������������������������������������������������������������������������������������������������������������������������������������������� 73 5. ANNEXES���������������������������������������������������������������������������������������������������������������������������������������������������������������������77 6. REFERENCES������������������������������������������������������������������������������������������������������������������������������������������������������������83 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 v List of Tables Table 1 Macroeconomic Indicators of Pakistan 14 Table 2 Health Security Expenditure across countries 16 Table 3 Healthy Security Expenditure (%) 19 Table 4 Number of Legal Documentations Issued for JEE Technical Areas 29 Table 5 Organizations Attached to the Ministry of National Food Security and Research 33 Table 6 Health Expenditure in Comparison with Other Sectors (%) 52 vi PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 List of Figures Figure 1 Total Health Security Expenditure (billion) 14 Figure 2 Health Security Expenditure per Year 15 Figure 3 Per Capita Health Security Expenditure in PKR (annual) 15 Figure 4 Provincial Share in Health Spending 17 Figure 5 Ministry-wise Health Security Expenditure (billion rupees) 17 Figure 6 Sources of Health Security Expenditures 20 Figure 7 Health Security Expenditure by JEE Technical Areas (excluding Immunization) 21 Figure 8 Health Security Expenditures by the JEE Pillars 22 Figure 9 Health Security Expenditure by Health Development Partners at Federal Level 23 Figure 10 NDMA Structure 38 Figure 11 IHR Implementation at Points of Entry 39 Figure 12 JEE Technical Areas Covered at the Federal and Provincial Levels 42 Figure 13 Number of JEE Technical Areas Covered at Federal and Provincial Levels 43 Figure 14 Stakeholder Mapping by Provinces and JEE Technical Areas 44 Figure 15 Pakistan’s GDP Growth (%) 49 Figure 16 Per Capita Health Expenditure (US$) 50 Figure 17 Pakistan—Macrofiscal Indicators 53 Figure 18 Role of the MoNHSR&C in the Budget Cycle 60 Figure 19 A Functional Summary Chart for Pakistan (2017-2018) 63 Figure 20 Fund Flow Mechanisms from Revenue Raising to Service Providers 64 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 vii ANNEXES Annex 1 List of Stakeholders 78 Annex 2 Notification of a Multisectoral National IHR Task Force 81 Annex 3 Re-Notification of a Multisectoral National IHR Task Force 82 viii PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 Acknowledgements This report has been prepared by a World Bank team, in collaboration with the Ministry of National Health Services, Regulations and Coordination (MoNHSR&C) of Pakistan. The team members include Dr. Sutayut Osornprasop (Task team lead), Dr. Mohsin Raza, Dr. Ali Mirza, Mr. Usman Bashir, Dr. Saira Kanwal, and Dr. Javeria Yousaf. The team would like to thank Dr. Aliya Kashif, Dr. Jahanzaib Sohail, and Ms. Shahnaz Meraj for their support. The team extends its thanks to Mr. Najy Benhassine, Ms. E. Gail Richardson, Ms. Trina S. Haque, Mr. Gailius J. Draugelis, and Dr. Lire Ersado for their guidance. Financial support for this work was provided by the World Bank—Vital Strategies Strengthening Public Health Capacities Trust Fund, and we would like to express appreciation to Mr. Mukesh Chawla and Ms. Rocio Schmunis. The report would not have been completed without the assistance of Dr. Sabeen Afzal Deputy Director Programs, MoNHSR&C. The World Bank team would like to acknowledge her valuable contribution and support. The team would like to express sincere appreciation to the following peer reviewers: Dr. Farah Sabih (Technical Officer, International Health Regulations, World Health Organization, Pakistan), Dr. Toomas Palu (Health Advisor, World Bank), Dr. Ajay Tandon (Lead Economist, World Bank), and Dr. Marion Jane Cros (Senior Health Specialist, World Bank). The team is also grateful for the contribution of officials and staff from MoNHSR&C, Ministry of Climate Change (MoCC), Ministry of National Food Security and Research (MoNFSR), Ministry of Finance, Ministry of Planning, Pakistan Bureau of Statistics, and their line departments; relevant provincial departments; and representatives from Health Development Partners including Asian Development Bank (ADB), Centers for Disease Control and Prevention (US CDC), Development Alternatives, Inc (DAI), Department for International Development (DFID), Food and Agriculture Organization (FAO), Global Fund, Islamic Development Bank (ISDB), Public Health England (PHE), United Nations Population Fund (UNFPA), US Agency for International Development (USAID), World Food Programme (WFP), John Snow, Inc. ( JSI), and World Health Organization (WHO). PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 ix Abbreviations AGPR Accountant General Pakistan Revenue FE&DSD Field Epidemiology & Disease Surveillance Division AHC Animal Husbandry Commission FELTP Field Epidemiology & Laboratory Training Program AJK Azad Jammu & Kashmir GHS Global Health Security AKUH Agha Khan University Hospital GHSA Global Health Security Agenda AMR Antimicrobial Resistance GLASS Global Antimicrobial Resistance Surveillance System APCC Annual Planning Coordination GoP Government of Pakistan Committee BHU Basic Health Units HSFAT Health Security Financing Assessment Tool CBOs Community-Based Organizations ICT Islamabad Capital Territory CCHF Crimean-Congo Hemorrhagic Fever IDSR Integrated Disease Surveillance and Response CD Communicable Diseases IFMIS Integrated Financial Management Information System CDC Centers for Disease Control IHR International Health Regulations CEPI Coalition of Epidemic Preparedness IPC Interprovincial Coordination Innovations CHE Central Health Establishment IPH Institute of Public Health COA Charts of Accounts JEE Joint External Evaluation CPEC China-Pakistan Economic Corridor KP Khyber Pakhtunkhwa DDMA District Disaster Management LHW Lady Health Worker Authorities DFID Department for International MERS Middle East Respiratory Syndrome Development DRAP Drug Regulatory Authority of Pakistan MoCC Ministry of Climate Change EMRO Eastern Mediterranean Regional Office MoF Ministry of Finance EPHS Essential Package of Health Services MoFA Ministry of Foreign Affairs EPI Expanded Program for Immunization MoNFSR Ministry of National Food Security and Research EPR Emergency Preparedness and Response MoNHSR&C Ministry of National Health Services Regulation and Coordination EPRCs Emergency Preparedness and Response MoPDR Ministry of Planning, Development Centers and Reforms FAO Food and Agriculture Organization MoPD&SI Ministry of Planning, Development FBR Federal Board of Revenue and Special Initiatives x PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 MTBF Medium-term Budgetary Framework PHE Public Health England NAP National Action Plan PHEN Public Health Engineering NAPHS National Action Plan for Health Security PHLD Public Health Laboratory Division NARC National Agriculture Research Center PoE Point of Entry NCD Noncommunicable Diseases PSQCA Pakistan Standards for Quality Control Authority NDMA National Disaster Management Authority PTA Pakistan Telecommunication Authority NDMC National Disaster Management RHC Rural Health Centers Commission NFC National Finance Commission RMNCH Reproductive, Maternal, Newborn, Child, Health NHA National Health Account SAARC South Asian Association for Regional Cooperation NHV National Health Vision SARS Severe Acute Respiratory Syndrome NIH National Institute of Health SDGs Sustainable Development Goals NHEPRN National Health Emergency Preparedness SFDRR Sendai Framework for Disaster Risk and Response Network Reduction NITAGs National Immunization Technical SWOT Strengths, Weaknesses, Opportunities, Advisory Groups and Threats NVL National Veterinary Laboratory UHC Universal Health Coverage OHSMART One Health Systems Mapping and UHC-BP Universal Health Coverage Benefit Analysis Resource Toolkit Package OHZDP One Health Zoonotic Disease USAID United States Agency for International Prioritization Development PAO Principal Accounting Officers VLMIS Vaccine Logistics Management Information System PARC Pakistan Agriculture Research Council WHO World Health Organization PDMA Provincial Disaster Management WFP World Food Programme Authorities PDMC Provincial Disaster Management Commission PEFF Pandemic Emergency Financing Facility PFM Public Financial Management PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 xi EXECUTIVE SUMMARY Executive Summary xii PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 EXECUTIVE SUMMARY Health security has evolved in Pakistan over the the provincial level, 72 departments were contacted last two dcades. In 2007, Pakistan became the sig- to collect the data. Moreover, 17 health development natory of the International Health Regulations (IHR) partners were contacted to collect the data at the federal convention to address public health risks in response and provincial levels. The quantitative analysis was to the global spread of disease. As a follow-up, focal done using the “expenditure analysis tool” developed points for implementing IHR were nominated, and a by the World Bank. The tool was calibrated to suit the multisectoral national IHR Task Force was identified. country’s context and was pilot tested at the federal In 2014 Pakistan was identified as a Phase-I country level. Besides that, a technical working group was supported under the Global Health Security Agenda developed to oversee the progress of data collection. (GHSA). Subsequently, in 2017 Pakistan became the The data collection was done in all four provinces and first country in the Eastern Mediterranean Regional federating areas including GB and AJK. Office (EMRO) of the World Health Organization to undergo the Joint External Evaluation (JEE) assess- FINDINGS ment to achieve GHSA targets. The JEE assessment resulted in the development of a five-year National The HSFA found that Pakistan had spent PKR Action Plan for Health Security (NAPHS) in 2018. The 78.77 billion (US$440 million) on average per revision of the NAPHS and conduct of the Health year on health security activities across 16 JEE Security Financing Assessment (HSFA) at federal and technical areas during 2017-2019. More than three- provincial levels are among the ongoing initiatives of quarters of spending on health security was carried out the Government of Pakistan. at the provincial level and a quarter at the federal level. Given the multisectoral nature of health security, The Health Security Financing Assessment health security spending not only represents the health (HSFA) seeks to support the national government sector but also spending from relevant government in developing financing strategies and prioritiz- agencies in charge of health; agriculture, environment, ing national preparedness plans. It further aims industries, and commerce, at the federal and provincial to strengthen financing systems that accelerate and levels. sustain progress toward effective health security. The HSFA achieved this by assessing the institutional ar- Pakistan health security spending can be compared rangements for health security, reviewing health secu- with other countries that have carried out HSFAs rity budgeting processes and resource allocation, and including Vietnam and Indonesia. Pakistan per evaluating the funding for specific health security ac- capita health security expenditure was US$2.96 in 2017, tion packages as defined in the JEE. US$3.96 in 2018, and US$2.07 in 2019. This expenditure as percent of GDP was 0.18 percent, 0.26 percent, and Pakistan commenced the HSFA in early 2020 0.17 percent respectively. Comparing this expenditure to augment the World Health Organization’s with that of Indonesia shows that it is quite significant (WHO) efforts to address the International as Indonesia’s per capital health security expenditure Health Regulations. The assessment was led by was US$1.23 (0.03 percent of GDP) in 2016, US$1.26 the Ministry of National Health Services Regulation (0.03 pecent of GDP) in 2017, and US$1.11 (0.03 and Coordination (MoNHSR&C) with technical and percent of GDP) in 2018. Vietnam also conducted financial support from the World Bank. Pakistan’s JEE the HSFA but it was limited to one year, that is, 2016. assessment guided the identification of health security Vietnam’s health security spending was equivalent to areas to be assessed under the HSFA. A total of 16 US$1.94 while the total health security expenditure was JEE technical areas were selected for the assessment in 0.09 percent of GDP. consultation with the MoNHSR&C. The HSFA was intended to calculate the financing A comprehensive methodology was adopted gap to promote national policy dialogue around to conduct HSFA. The sample at the federal level health security financing but there were limitations. includes three ministries and ten line departments. At Pakistan conducted the JEE assessment in 2016 that PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 xiii EXECUTIVE SUMMARY highlighted gaps in implementing IHR across the 19 federal level immunization gets most of the funding JEE technical areas. The assessment resulted in the (almost 95 percent of federal-level health security development of the NAPHS, which aims to address funding is allocated to immunization). Real-time gaps pointed out by the JEE and strengthen IHR core surveillance, national laboratory, and workforce capacities in Pakistan. Subsequently, these gaps were received some funding but it was inadequate. The translated into activities and the costed NAPHS was remaining 12 JEE technical areas receive very little or no developed. One limitation of NAPHS was, it only funding, such as IHR coordination, reporting, medical covered the costing for gaps, and it was difficult to use countermeasures, risk communication, emergency it as a baseline costing. In contrast, the HSFA was a response operations, food safety, preparedness, etc. At comprehensive exercise to record the overall actual the provincial level, 9 out of 16 JEE technical areas expenditure across the JEE areas. Therefore, the direct received a significant budget, while 6 JEE technical areas comparison of NAPHS with HSFA to calculate the received a very low budget, such as zoonotic diseases, financing gap was not possible. risk communication, Antimicrobial Resistance (AMR), medical countermeasures, workforce development, The revision of the provincial NAPHS is overdue and preparedness. Many reasons could be attributed to calculate the financing gap for IHR. The total to these disparities but most important is the lack of cost of the original NAPHS from 2017 was PKR 111 stewardship and commitment by MoNHSR&C and its billion; the provincial share was PKR 106.7 billion (96 provincial counterparts to increase the health security percent), and the federal share was PKR 4.48 billion budget. (4 percent). In 2021, the government decided to revise NAPHS at the federal and provincial levels to estimate At the provincial level, there is a wide disparity completed and remaining activities. The federal- in health security spending across JEE technical level costing was comprehensively revised in 2021 to areas. During the period of the HSFA (2017-2019), PKR 3.85 billion. However provincial revisions were Punjab had spent PKR 55.1 billion (average per year) never initiated. The funding gap for IHR can only be on 14 JEE technical areas, while Sindh spent only PKR calculated if the NAPHS is revised at the provincial 0.6 billion (average per year) covering 10 JEE technical level to ascertain what activities have been completed areas. Health security spending (average per year) in and what remains. The MoNHSR&C was inclined to other provinces was as follows: KPK PKR 2.2 billion pursue the revision of NAPHS at the provincial level (covering 8 JEE technical areas), Balochistan PKR 1.56 but the funding could not be secured. billion (covering 7 JEE technical areas), GB PKR 0.83 billion (covering 6 JEE technical areas), and AJK PKR The HSFA has helped to prioritize JEE areas at 0.026 billion (covering 6 JEE technical areas). Annual the federal and provincial levels using the JEE per capita health security expenditure also varies across scores. JEE assessment assigns scores to each JEE provinces. While health security spending in Punjab and technical area (1 represents no capacity in the selected GB was PKR 501 (US$3.98) and PKR 694 (US$5.52) JEE area, 2 and 3 represent developed or demonstrated per capita, Sindh spent only PKR 12 (US$ .09) per capacity, and 4 represents sustainable capacity). The capita. Health security spending per capita in other HSFA revealed that some of the areas which get very provinces and federating areas was as follows: KPK low JEE scores like Antimicrobial resistance, and PKR 63 (US$0.50), Balochistan PKR 130 (US$1.03), Preparedness (scored 1) are still under-financed at the and AJK PKR 66 (US$0.36). federal and provincial levels. Out of the total health security spending, less the 1 percent was spent on these Various sources finance health security at the two JEE areas at the federal and provincial levels. Some federal and provincial levels but the current health of the other JEE areas that need prioritization at the security financing arrangement is not sustainable. federal and provincial levels are: Zoonotic Disease, At the federal level, health security is mainly financed Risk Communication, and Workforce Development. through the development budget (86.3 percent), followed by external sources (8.6 percent), own sources There is a disparity in funding for JEE technical (3.8 percent), and the recurrent budget (1.2 percent). At areas at the federal and provincial levels. At the the provincial level health security is financed through xiv PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 EXECUTIVE SUMMARY the regular budget (63.4 percent) and development Islamabad (referral lab), and the Microbiology Lab of budget (36.6 percent) only. The development budget the Institute of Public Health (IPH), Lahore. is designed to support short-term activities that last a maximum of two or three years, hence it is not a Some of the JEE technical areas remain neglected sustainable source of financing. Furthermore, the and require immediate attention. Key JEE expenditure from the development budget is meted technical areas including points of entry, food safety, through the consolidated fund of the Government, risk communication, and preparedness remain under- which lapses at the end of each year and any unused resourced. A Planning Commission document (PC-I), amount is returned to the Treasury. The recurrent for points of entry has been approved but it will some budget is a more sustainable source of financing; time for funds release from the development budget. however, a very small fraction of the recurrent budget Presently, there exists no precise and integrated system goes to health security. To make health security of monitoring and surveillance to mitigate health financing more sustainable, there is a need to ensure and economic losses associated with a substandard that priority health security interventions become food safety system in Pakistan. A risk communication part of the recurrent budget. This could be achieved strategy has been developed but implementing it if Health security becomes part of the “schedule of requires financing support. Similarly, preparedness authorized expenditure”, that is, expenditure approved activities need strengthening as the National Health in the budget according to the expenditure heads. Emergency Preparedness and Response Network (NHEPRN)—an organization to deal with the mandate According to the HSFA, developments and of Emergency Preparedness and Response (EPR)—is investments have taken place in selected JEE underfinanced and insufficiently staffed. technical areas at the national level, but these are not consistent across all technical areas, with A thorough understanding of the macroeconomic some JEE technical areas being neglected. The and fiscal context, including the fiscal space, is JEE assessment highlighted gaps in implementing IHR critical to support and strengthen health security across the 19 JEE technical areas. In the last five years, interventions under the National Health Vision some of the JEE technical areas have gained more (NHV) 2026 and provincial health strategies. The attention and resources than others, including AMR, health sector is intrinsically linked with the macrofis- biosafety, immunization, laboratory, and surveillance. cal context of the country. Any proposals to raise the In the area of AMR, the National Action Plan for AMR health security budget without understanding the fis- and the Global Antimicrobial Resistance Surveillance cal context are unlikely to achieve their intended out- System (GLASS) Pakistan have been developed along comes. NAPHS was developed in 2017 and estimated with the notification to provincial focal points to a funding gap for health security of PKR 4.54 billion support implementation. In the area of biosecurity, (US$25.36 million) for the next five years. However, Pakistan has formulated the “National Biosafety and this was done without understanding the fiscal enve- Biosecurity Policy”, and a functional biosafety level lope at that time. As a result, only 38 percent of the (BSL-3) laboratory has been established at the national funding gap has been secured for the implementation level. Immunization is the area that has benefited most of NAPHS in the past five years. With the current fis- from the reforms. National Immunization Technical cal deficits, there is a need to introduce innovative ways Advisory Groups (NITAGs) have been constituted for i.e. Public Private Partnership to increase the fiscal immunization. To ensure a fully functioning vaccine space to support priority health security interventions. supply, a Vaccine Logistics Management Information System (VLMIS) is in place across Pakistan. There have Most of the planned interventions for IHR imple- been major improvements in diagnostics capacity to mentation at the provincial level have either not support timely detection, prevention, and control of started or are still incomplete since 2017, such infectious diseases during outbreaks and epidemics, as: including the establishment of such state-of-the-art • Notification of Provincial IHR Task Forces laboratories as the Public Health Laboratories Division • Notification of IHR focal persons in health and (PHLD) at the National Institute of Health (NIH) other sectors at the federal and provincial level PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 xv EXECUTIVE SUMMARY • Communication to the chief secretaries of each The role of the Ministry of Health in budget province for intersectoral coordination and re- formulation and execution is limited. During the source allocation budget planning, the MoNHSR&C along with its pro- • Development of PC-I for key prioritized technical vincial department seldom develop or discuss the in- areas at the provincial level. vestment case with the Ministry of Finance and other • Periodic supervision to ensure activities are im- stakeholders. There is usually no dialogue between the plemented according to target at all levels, starting Ministry of Finance and health departments on refin- from the Ministry, down to provincial and district ing the budget structure for health, or costing for a spe- levels. cific policy change. • Recruitment and deployment of the required hu- man resources for health security and OneHealth The budget release process has resulted in un- at all levels. derspending for health security areas. Numerous checks are built in the release process, and the same is In absence of implementation of planned activities, applied at the payment stage instead of at the commit- the provinces are still not clear about their role in ment stage. Resultantly, the release process is subject achieving the level of health security required by IHR to multiple controls and numerous checks, which have 2005. Provincial PC-Is that assure sustainable financing made budget execution cumbersome. for health security are pending and there is no provin- cial-level plan to allocate funds for the neglected JEE Fragmented revenue is another issue for health se- technical areas. Moving ahead, MoNHSR&C should curity financing. Financing from the health develop- take a proactive role in implementing the monitoring ment partners for health and non-health departments activities as envisaged. is usually not aligned with the government financial systems and cannot be easily traced. As a result, es- Multiple constraints limit the efficiency of the timating the fiscal envelope for health security is not Public Financial Management (PFM) process for feasible. health security, such as: The budget approval process in the context of Input-based budgeting is one of the barriers to fiscal decentralization is a PFM issue. The 18th financing health security expenditures. Under this Amendment to the Constitution of Pakistan delegat- system, the budget is allocated to entities, i.e. ministries, ed most public service delivery functions to the pro- departments, divisions, etc. using object elements like vincial governments, including PFM. However, fiscal salaries, operating expenses, etc. One limitation of this decentralization has not been fully implemented and system is that the funds cannot be allocated directly to impedes budget execution of several programs, includ- JEE technical areas, nor can the expenditure on JEE ing of health security related programs. The budget ex- technical areas be tracked from the government finan- ecution for IHR involves multiple layers of checks by cial system. numerous officials in budget execution, implementa- tion, release processes, etc. Priority health interventions are not part of Medium-Term Budgetary Framework (MTBF). MTBF is a tool used to link the health intervention with the budgeting cycle. However, the use of MTBF at the federal and provincial levels is limited because of inadequate training of finance staff to develop ex- penditure and revenue projections, and pursue MTBF with the Ministry of Finance. As a result the NAPHS costing was never translated into MTBF at the federal and provincial levels. xvi PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 EXECUTIVE SUMMARY RECOMMENDATIONS Achieving preparedness for health security is a sequential process and should be followed Pakistan can use multiple ways to create fiscal accordingly. It starts with JEE assessment that space for IHR. First, with a restricted budget and evaluates the country’s preparedness capacities across competing priorities, the Government of Pakistan key technical areas and recommends priority actions. could use an allocative efficiency analysis. It will help The recommendations are then translated into the to determine whether it is possible to allocate funding National Action Plan for Health Security (NAPHS)—a from low-priority areas in other sectors to health secu- planning tool to accelerate the implementation of rity. Second, through the HSFA qualitative assessment, IHR core domains. Once the costed plan has been there is anecdotal evidence of technical inefficiencies developed, the next step is to prepare a financing in health security spending, including the inability to plan to work out how to finance this plan, including spend the allocated budget within the required time identifying the sources of financing. The financing lines. This issue can be addressed by building capaci- plan is followed by an investment case to persuade ty at the federal and provincial levels on commitment and bring together the political and social support for accounting. Third, Pakistan still has room to further mobilizing resources as per the financing plan. Fi- increase excise taxes on tobacco and unhealthy food nally, a change management strategy is required to products that are high in fat, sodium, and sugar to in- engage and coordinate with the relevant stakeholders to crease overall government revenues, and then allocate support implementation. these resources for health security, either through soft or hard earmarking. Lastly, donor and development Developing a financing plan, investment case, and partner assistance, including civil society organiza- change management strategy is critical in achiev- tions and the private sector, could improve the fiscal ing IHR core capacities. Pakistan started well and space and provide supplementary resources. Howev- conducted the JEE assessment in 2016, developed er, the government also needs to be able to effective- NAPHS in 2017, and accordingly costed the plan. ly coordinate the use of external sources of funding, However, it did not follow through by developing a fi- direct them to priority health interventions, and avoid nancing proposal. Consequently, a significant portion duplication. of NAPHS remained unfunded till 2021, and only one- third of activities were financed by the Government A proper mechanism for multisectoral/multidis- or through the assistance of development partners. ciplinary coordination, communication, and part- The investment case to attract political and economic nerships to prevent, detect, assess, and respond support for improving health security and pandemic to any public health event or emergency must preparedness was never initiated. The costed plan has be in place. Provincial actors working on different therefore not become part of the national budget cycle IHR areas must monitor their roles and responsibili- to secure sustained financing. Finally, a change man- ties to ensure that IHR issues are being addressed at agement strategy that facilitates the committed engage- the provincial level. When the provincial government ment of relevant stakeholders, was not drafted. Paki- is responding to emergencies, there is often a need to stan is currently pursuing the revision of NAPHS at coordinate between its various ministries and other the federal and provincial levels to document progress provincial organizations. There is a need for a single made in the implementation of NAPHS over the last uniform plan to tackle emergencies which should re- few years. One way forward is to link the NAPHS re- flect realistic assumptions of the amount and rates of vision exercise with the development of the financing release of materials. There mus t be a defined role for plan, build the investment case, and articulate a change health security agencies, including the animal health management strategy. This will ensure continuity in sector, human health sector, and environment/wild- efforts to achieve the IHR core capacities. life sectors, to cover all areas of health security-related activities at national and provincial levels. Advocacy must be conducted to ensure that a proper coordination mechanism in health security is instituted as soon as possible. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 xvii EXECUTIVE SUMMARY Having a baseline expenditure on Health Securi- priority health interventions are either program-based, ty, a NAPHS revision at the provincial level could for example, essential health packages, IHR, etc., or be the next step. The current HSFA has documented disease-based (for example, communicable diseases, the spending on 16 JEE technical areas at the federal noncommunicable diseases, etc.). Program-based or and provincial levels from 2017-2019. This was the first output-based budgets are closely aligned with health attempt to confirm the actual expenditure on the se- sector priorities and make it easy to allocate and mon- lected JEE areas and has established a baseline for the itor the health allocation by the problem of the pro- subsequent assessments. The revision of NAPHS now gram, services, or packages. The payment released in will help to identify the financing gap between the ac- the output-based budgeting could also be less cumber- tual expenditure (HSFA) and the desired expenditure. some as the spending unit, and also the Ministry of The NAPHS revision will produce the indicative cost Finance will know where the budget will be spent. The estimates to improve the IHR implementation in the government should use tools like the Medium-Term coming years. Budgetary Framework (MTBF) to move from input to output-based budgeting. Tracking the progress of IHR is the key in the post-pandemic scenario. A way forward is to digi- The MoNHSR&C and provincial departments of talize the NAPHS using the current digital platform of health should build their capacity to properly de- the MoNHSR&C. Currently, the ministry is maintain- velop and apply MTBF by making it output-based ing a Pakistan Health Information System (PHIS) to and including IHR. While the MoNHSR&C has de- report progress on immunization, nutrition, and other veloped MTBF, the current MTBF is still input-based health areas. Digitalization of NAPHS will ensure the and does not reflect the financial commitments re- routine monitoring of NAPHS. Progress on activities quired to achieve health interventions including IHR, will be updated periodically by the relevant ministry or NAPHS, and UHC packages. So far there is a shortage line department. An online dashboard will also help to of technical experts at the MoNHSR&C who can un- identify completed activities, sources of funding, im- derstand, relate and implement the MTBF with the Is- plementing agency, project name, etc. Each provincial lamabad health vision, NHV, and other provicial health line department will be responsible for updating the strategies. data on the dashboard, and gaps will be highlighted au- tomatically. Through digitalization, a mechanism could Immediate attention is required to revise the be developed that could link the revised costing with Charts of Accounts (CoA) for the current PFM the JEE score to review implementation progress to- system to track and report the fund allocation ward IHR capacities. These results could then be fed and spending on health security. Resource mapping into operational planning and prioritization. The digi- and expenditure tracking of the national health strat- talization of the NAPHS will also support the second egy and national health account (NHA) are exercises JEE assessment due later in 2022. that require heavy data collection and sometimes fail to become routine because they are time-consuming Comprehensive PFM reforms are required to align and expensive. Having a solid integrated financial man- health financing to priority health interventions agement information system (IFMIS) that can gener- including IHR. Despite the policies in place to imple- ate budget and expenditure data in the health sector ment output-based budgeting, only input-based bud- concerning IHR, NHV/UHC, and provincial health geting is in practice at the federal and provincial levels. sector strategies is a goal that can institutionalize those An input-based budget not only limits the budget allo- exercises. This requires that the CoA, by which IFMIS cation to the health sector but also affects the cash re- is organized, allows codifying the health budget by pri- lease policy. Input-based budgeting classifies, organizes, orities, and sub-priorities of the health sector, includ- and releases the budgets as per the entity (ministry and ing health security sub-priorities. Therefore the cur- departments, etc.) or by the administrative lines (sal- rent CoA must be revised to meet IHR requirements. aries, travel, etc.). This system of budgeting does not suit health services and health security as most of the xviii PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 EXECUTIVE SUMMARY The process of budget release should be part of Lastly, but importantly, there is a need to increase the Government’s PFM reforms agenda. The fed- awareness on investing in health security and pan- eral and provincial governments tend to manage the demic preparedness, as well as economic risks and approved budget through a “mechanism of releases” returns, including making “health security is eco- which significantly reduces the overall usefulness of nomic security” a reality at national and provincial the budget as a tool to create fiscal discipline, economy, levels. As clearly demonstrated by the COVID-19 pan- and transparency. The budget is released to spending demic and previous pandemics, the costs associated entities in three tranches, that is, 30 percent in the first with inaction and the lack of pandemic preparedness quarter, 30 percent in the second quarter, and 40 per- are immense. Yet, shortly after each pandemic, gov- cent in the third quarter. This release process in effect ernments and ministries of finance in many countries works against procurements to support health secu- tend to become complacent and deprioritize invest- rity and health services. In many cases, payments for ments in health security and pandemic preparedness, procurement cannot be done piecemeal. For instance, only to bring them back when the next pandemic oc- when equipment is required to be purchased in one go, curs. Hence, there is a need for continuous and per- then the invoice needs to be processed for the whole sistent attention and investments in health security and of the equipment. In such cases, the procuring agen- pandemic preparedness; and the clear evidence that cies are not authorized to spend the whole of the bud- “health security is economic security” is key to making get for the physical asset in the first quarter. If they opt the investment case. to wait two or three quarters, this reduces utilization of the budget in the first quarter, which attracts ob- jections to the non-release of funds in the second and third quarters by MoF. Due to this process, at times the entities refrain to procure the health and laboratory equipment because of the fear that funds might not be released on time and they would have to face liti- gation by the suppliers. Furthermore, the first tranche of the budget is usually released only around the end of the first quarter or in the second quarter, and hence responsible units usually do not have a budget for im- plementation in the first quarter, leaving them with just nine months out of a full fiscal year to implement. The delays in releasing the first tranche usually contribute to delays in subsequent tranches. An immediate solution to this problem is preferably to release the first tranche within the first month of the fiscal year to allow for a full year of implementation, and also make an excep- tion to the “30 percent-30 percent-40 percent policy” in case there are reasonable needs to release more than 30 percent of an annual budget in the first quarter. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 xix INTRODUCTION 01. Introduction 1 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 INTRODUCTION Health security has gained importance in the face 2017 witnessed further developments in the areas of of COVID-19. It has demanded a relook at the health security. The WHO initiated a health emergen- country’s preparedness and response capacities cies program. The CEPI was established to launch in- and the need for sustainable financing for health dependent research on emerging infectious diseases. security. WHO has defined public health security as The World Bank designed a Pandemic Emergency Fi- “the activities required, both proactive and reactive, nancing Facility (PEF) for the less privileged countries to minimize the danger and impact of acute pub- to avail of a financing facility in the instance of major lic health events that endanger people’s health across outbreaks.2 The purpose of all these progressive devel- geographical regions and international boundaries”. opments was to make member states aware of IHR In recent decades, diseases like Severe Acute Respira- prevention, detection, and timely response to public tory Syndrome (SARS), Middle East Respiratory Syn- health emergencies. Moreover, member countries were drome (MERS), and Ebola have been shown to have required to provide sustainable financing for critical a massive impact on the lives of millions of people capacities, viz. IHR coordination, surveillance systems, across the globe. At present, coronavirus (COVID-19) laboratory, and emergency response operations. has posed an unprecedented challenge to public health and has highlighted gaps in sustainable financing for The Joint External Evaluation (JEE) was the re- health. Addressing these issues has become more im- sult of the extended commitment from develop- perative when comprehended in the context of Uni- ment partners to respond to public health risks. versal Health Coverage (UHC) which promises equity The strategic actions of the World Bank and WHO in health without financial hardships. were soon translated into assessments and plans. The initial response of most countries was to undergo the The concept of health security has evolved only in JEE assessment to assess their capacity to prevent, de- recent years. The need for health security preparedness tect, and rapidly respond to public health risks occur- only grew post-Ebola when WHO convened a meet- ring naturally or due to deliberate or accidental events. ing at its Regional Office in Africa in July 2015.1 The The JEE was conducted using a tool (JEE tool) devel- aim was to build resilience in health security prepared- oped by the WHO that enabled countries to identify ness and response activities. The meeting demanded gaps in core IHR capacities and prioritize their inter- technical and financial commitments from relevant ventions. The first edition of the tool was made avail- stakeholders. This meeting led to a subsequent meet- able in 2016, followed by the second version in 2018. ing on health security in Bali, Indonesia, in June 2016. However, the tool was only an assessment helping a Participants from 52 countries and 28 organizations country identify the gaps while the concrete cost action showed their commitment to building momentum plans that implement the proposed intervention were on sustainable Global Health Security (GHS) actions. yet to follow. Simultaneously, the World Bank created the Interna- tional Working Group (IWG) on financing prepared- The JEE translated into the National Action Plan ness in November 2016. The group aimed to advo- for Health Security (NAPHS) in Pakistan. In 2016, cate for strengthening pandemic preparedness and the WHO secretariat developed the guidelines for core public health capacities in compliance with IHR NAPHS. A three-tier approach was used, comprising and the World Organization for Animal Health (OIE) inception, development, and implementation to identi- standards. fy priorities for health and subsequently translate them into actions. The guidelines explained the steps for a Initiatives such as the Coalition of Epidemic SWOT analysis (Strengths, Weaknesses, Opportunities, Preparedness Innovations (CEPI), and the and Threats analysis), stakeholder assessment, priori- Pandemic Emergency Financing Facility (PEF) tization of technical areas, costing, and budget alloca- have paved the way for health security. The year tion. Tanzania was the first country to translate the 1 Building Health Security Beyond Ebola. https://www.who.int/ihr/beyond_ebola/en/ 2 Building Health Security Beyond Ebola. https://www.who.int/ihr/beyond_ebola/en/ PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 2 INTRODUCTION JEE recommendations into priority actions in the form try on how to scale up the budget for health security ozNAPHS, followed by Pakistan and Eritrea (Mgham- and provide concrete evidence for the same. Further, it ba et al., 2018). will also be in alignment with the Government’s health reform agenda limiting the duplication of activities The World Bank developed the Health Security and accelerating progress toward achieving the targets Financing Assessment Tool (HSFAT) to comple- set by the Sustainable Development Goals (SDGs) ment JEE and NAPHS. The tool was developed by a 2030. The MoNHSR&C may at a later stage require a task force composed of technical experts and high-lev- fiscal space analysis to explore additional funding sourc- el representatives from Vietnam, Indonesia, Myanmar, es to bring these essential health system capacities to Cambodia, development partners, WHO, World Orga- realization. nization for Animal Health (OIE), Food and Agricul- ture Organization (FAO), Government of the Unit- The HSFA is critical for Pakistan to close the ed States of America, Government of Australia, and funding gap that exists in departments managing other key stakeholders. The purpose of HSFAT was JEE technical areas. Pakistan has made significant to support national governments to develop financing progress in implementing the IHR regulation and has strategies that link to prioritized national action plans already developed a Five Year NAPHS. However, to for health security and enable countries to develop a actualize the plan, the financial commitments made so strong and sustainable financing system. far from the public sector are not sufficient and need to be revisited. The National Institute of Health (NIH) Islamabad, for example, is the focal point to deal with 1.1. JUSTIFICATION FOR HEALTH IHR at the federal level and deals with seven JEE tech- nical areas; however, its financial allocation from the SECURITY government budget is limited to employee-related ex- penses and retirement benefits, etc. Furthermore, the Pakistan is perusing various health initiatives to National Health Emergency Preparedness and Re- achieve the goal of UHC. Pakistan is currently im- sponse Network (NHEPRN) is also underfinanced plementing major health-based initiatives, such as the and has inadequate human resources to deal with the National Health Vision (2016-2025), Reproductive, mandate of Emergency Preparedness and Response Maternal, Newborn, Child, Health (RMNCH) Strategy, (EPR). The HSFA thus will help to identify the funding development of the Universal Health Coverage Bene- mechanism for key departments overseeing JEE tech- fit Package (UHC-BP) including the Essential Package nical areas at the federal and provincial levels. It will of Health Services (EPHS), Intersectoral Interven- also contribute to determining the funding gaps and tions for Lady Health Workers (LHW) Strategic Plan proposed mechanisms for revenue mobilization. for 2022-2027, and NAPHS. All these strategies and relevant policy documents address the major needs of the health system and are consensus-based documents 1.2. THE OBJECTIVE OF THE HSFA with provincial buy-in. The NAPHS, for example, is meant to bring the country in compliance with IHR. The purpose of the HSFA is to understand the ex- At the same time, UHC-BP under the umbrella of the isting state of affairs for health security financing SDG target will contribute toward providing quali- in Pakistan and the role of federal and provincial ty health services without financial hardship to the governments, and development partners in achiev- population at large. ing the targets outlined in the Five Year NAPHS. In response to the urgent need to increase investments The HSFA is a step forward to check Pakistan’s in preparedness and response, the HSFA aims to ex- readiness to achieve the IHR core capacities. The plore the existing financing arrangement for health se- HSFA will evaluate the current status of health expen- curity at the federal and provincial level with a focus on: diture on JEE technical areas and identify the fund- (i) making a business case for increasing investments ing gaps in achieving the desired level of IHR core in preparedness, response, and recovery mechanisms; capacities. The HSFA will directly inform the minis- (ii) identifying approaches to prioritize investments 3 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 INTRODUCTION within existing budgets; (iii) providing options for incremental domestic resource mobilization; and (iv) catalyzing and supporting domestic investments in preparedness and response through development assistance. 1.3. ORGANIZATION OF THE REPORT The report is divided into four sections. The following section discusses the methodology of the assessment. The results of the qualitative and quantitative assess- ments are discussed in Section 3. Section 4 covers the findings and recommendations. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 4 METHODOLOGY 02. Methodology 5 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 METHODOLOGY The HSFA was the collaborative effort of the federal and provincial levels were identified with the MoNHSR&C, provincial departments, and the help of MoNHSR&C. The desk review also helped to World Bank. The MoNHSR&C conducted the HSFA understand the challenges in implementing the IHR. at the federal and provincial levels with the technical and financial support of the World Bank. The assess- ment captured expenditure on 16 JEE technical areas 2.2. THE SAMPLE during the last three financial years: 2017, 2018, and The sample for the HSFA was chosen by keeping 2019. The data collection took place between March in mind the devolved health setup. The health sec- 2020 and December 2021 in collaboration with stake- tor became a provincial subject after the 18th Amend- holders working in the areas of health security. ment to the Constitution of Pakistan. Consequently, the data on health security expenditure is not available The data collection for HSFA was interrupted due at one ministry or department at the federal or provin- to COVID-19 and a revised methodology was de- cial level. All the provinces and federating areas are re- veloped. The duration of data collection took longer sponsible for building their preparedness capacities as than expected as in February 2020, the first case of per their provincial NAPHS and keeping the record of COVID-19 was reported in the country. The pandemic health security expenditure accordingly. With this con- restricted travel within the country and most staff in text in mind, a series of consultative meetings were held line ministries and development partners were forced with respective ministries and departments to select the to work from home. The data collection methodology sample. This assisted in identifying the ministries and was revised and both online and face-to-face meetings their line departments dealing with the specific health were held (where possible). International consultants security area at the federal and provincial levels. from the World Bank and their local counterparts con- stituted the team with technical support from MoN- Devolution has resulted in a shared responsibili- HSR&C. The data was collected at the federal level, ty on health matters at the federal level ministries provincial level, and the federating areas on the 16 JEE and provincial line departments. At the federal lev- technical areas, namely: el, three ministries, namely: MoNHSR&C, Ministry of Climate Change (MoCC), and Ministry of National (i) National legislation, policy, and financing (ii) IHR Food Security and Research (MoNFSR) look after the coordination, communication, and advocacy (iii) An- health security areas. At the provincial level, various timicrobial resistance (AMR) (iv) Zoonotic disease (v) departments are working in the areas of health secu- Food safety (vi) Biosafety and biosecurity (vii) Immu- rity including but not limited to provincial Expanded nization (viii) National laboratory system (ix) Real-time Program for Immunization (EPI) programs, provincial surveillance (x) Reporting; (xi) Workforce develop- TB control programs, RMNCH programs, etc. Simi- ment (xii) Preparedness (xiii) Emergency response op- larly, departments other than health are also working erations (xiv) Medical countermeasures and personnel in the areas of health security, such as the Agriculture deployment (xv) Risk communication and (xvi) Points Department, Environment Department, Livestock of entry. Department, etc. 2.1. DESK REVIEW The sample was taken from ministries, depart- ments, and development partners that represent- A desk review was conducted to understand the ed a significant health security expenditure at the country’s context, mapping of key stakeholders, federal and provincial levels. A total of three minis- and trends in health security at the federal and tries and ten line departments were selected at the fed- provincial levels. All the available information re- eral level to collect the expenditure on health security. garding health security activities was gathered and or- The HSFA team visited 72 departments at the provin- ganized during the desk review. Key stakeholders at the cial level including federating areas to collect the data. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 6 METHODOLOGY However, data from 52 departments were collected as 2.3.1 Qualitative analysis some departments were either not working in the areas of health security or the data for previous years was A purposive sampling method was used to choose not available. Development partners have also contrib- the participants. The inclusion criteria were based uted to health security expenditure through on-budget on participants who had sufficient work experience and off-budget support. Seventeen development part- in the field of international health regulations (IHR) ners were identified with the help of ministries work- and could provide the necessary information. After ing in the areas of health security. The complete list the mapping of relevant stakeholders at the national of federal and provincial ministry/departments, and and provincial levels, a formal request was sent to the development partners working in the areas of health participants for in-depth interviews and small, focused security is given in Annex 1. Other concerned depart- group discussions. ments were also visited, but the discussion with rele- vant personnel revealed that the expenditure on health The data collection was done in two phases at the security was either very insignificant or not available to federal and provincial levels. The first round of inter- these departments. views was conducted with representatives from MoN- HSR&C, MoNFSR, and MoCC at the federal level. 2.3. THE APPROACH The departments covered under these ministries were: Expanded Program for Immunization (EPI), NIH, The current PFM in the country and limited NHEPRN, Central Health Establishment (CHE), Na- knowledge about health security at the federal and tional Veterinary Laboratory (NVL), Pakistan Agricul- provincial levels led to a mixed method of data ture Research Council (PARC), livestock wing, Pakistan gathering. At the preliminary stage of data collection, Standards for Quality Control Authority (PSQCA), some disparities were found in health security expen- National Disaster Management Authority (NDMA), diture as revealed by the finance department versus Drug Regulatory Authority of Pakistan (DRAP), and the technical team at the Ministries/Departments. For EPA. The second round of interviews was done at the example, training was conducted on AMR at NIH ex- provincial level by identifying stakeholders in the afore- plaining basic microbiology techniques. However, the mentioned departments functioning at the provincial detail of expenditure as per the JEE technical area, that level. Interviews from developmental partners were is, AMR was not available to the finance department also conducted to ascertain their support for health se- mainly because the financial system in Pakistan, both curity at the federal and provincial levels. at the provincial and federal levels, is not designed to record and report the health security expenditure. The current codes available in government financial sys- 2.3.2 Quantitative analysis tems are not designed as per the JEE technical areas The HSFA quantitative analysis was done using and limit data extraction. To estimate the correct ex- the “expenditure analysis tool” calibrated to suit penditure on health security, it was necessary to consult the country’s context. The HSFA tool was developed the technical team at the ministry/department. Under by the World Bank team and had been used successful- such circumstances, the mixed method was adopted ly in Vietnam to collect health expenditures. MoNHS- to minimize contradictions between quantitative data R&C recommended adjustment to the tool as health collected from the finance department and qualitative is organized differently in Pakistan. A workshop at the findings shared by the technical team. A brief descrip- federal level was organized and coordinated by MoN- tion of each method is described below. HSR&C to review the tool. Health security experts and relevant officials from the Ministry of Planning, Devel- opment and Special Initiatives (MoPD&SI), MoNFSR, MoCC, Pakistan Bureau of Statistics (PBS), WHO, and FAO attended the workshop. Experts from the two- day workshop agreed that the tool required calibrations before it could be used to collect the expenditure data 7 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 METHODOLOGY in Pakistan. The panel of experts further proposed a 2.4 DATA COLLECTION pretest of the tool with a line department at the fed- eral level. The tool was calibrated in multiple sessions 2.4.1 Federal level with stakeholders representing government and devel- opment partners. The tool was reviewed and was fully In the first phase, data from the ministries and de- endorsed by the workshop participants for the pretest. partments were collected. The data from donors was collected in the second phase. The data collec- The HSFA tool was finalized and pilot tested to tion at the federal level was initiated with preliminary ascertain the validity of the instrument. The pre- meetings with the relevant departments and ministries. test of the HSFA tool was conducted at the NIH on The MoNHSR&C issued a letter seeking approval to January 13, 2020. Participants confirmed that the tool nominate the focal points for the assignment. All the works well in the Pakistan context and that the World ministries and their line departments were contacted Bank team should proceed with data collection. The in the first phase (March to June 2020). In the second final approved tool covered 16 JEE technical areas cov- phase, development partners were requested for data ering both human and animal health. It further clas- collection (August to September 2020). sified the spending by government departments and development partners. The tool was able to capture the Data collection was a challenge because of the expenditure from the recurrent budget, development current inability of PFM to track health expendi- budget, external aid, and own sources.3 It also captured ture by JEE technical areas. In the primary meeting, sources of funds, funding by implementing partners, the scope of the assignment was explained to relevant location, and type of expenditure from donors. personnel in departments and ministries, and a ques- tionnaire was shared with government departments. As 2.3.3 Technical Working Group the questionnaire was not designed according to the government financial system, often the consultant was A technical working group for HSFA was formu- referred to the finance department. In-depth interviews lated to oversee the progress of HSFA in Pakistan. with both the finance and technical teams were con- The group was comprised of relevant representatives ducted to collect the required information as per the from MoNHSR&C, Ministry of Finance (MoF), MoP- shared template. The finance department often shared D&SI, MoNFSR, MoCC, PBS, WHO, and FAO. The the hard copies of expenditure or the Journal Ledger role of members of the technical working group was to extract the data and match it with the JEE technical to: areas.4 The consultant extracted the health security ex- penditure data with the help of technical experts. The a. Guide and coordinate technical support, policy, filled questionnaire was emailed to the respective focal administration/logistics for data collection and points for their concurrence to ensure the data’s reli- implementation of HSFA; ability and accuracy. b. Strengthen advocacy at the national and subna- tional level to enhance political and financial com- In the second phase, data from the development part- mitment for sustainable health security financing ners were collected. Due to the outbreak of COVID-19, and leadership, and identify national/provincial most of the offices were closed, or the staff was work- champions; ing from home. A virtual meeting was conducted in c. Advise on opportunities to address knowledge and August 2020 to brief development partners on the capacity gaps to support sustainable health security HSFA in Pakistan. The development partners were financing and support the process. briefed on the objective of the HSFA and the guid- ing principles through which the financing assessment would operate. 3 Own Source Revenues: All revenues collected by the state and local governments from their own sources (excluding federal transfers). 4 Journal Ledger: The main accounting record of a company or organization. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 8 METHODOLOGY 2.4.2 Provincial level concept and status of health security (IHR). Lastly, the COVID-19 pandemic considerably limited travel in A methodology similar to the federal level was provinces, and partial and complete lockdown made adopted to collect data at the provincial level. A the data collection very difficult. letter was sent from the MoNHSR&C to all the provin- cial IHR focal persons and line departments in Decem- The devolved health set up in the country proved ber 2020. A coordinated session was conducted with all to be a challenge in both qualitative and quantita- provincial IHR focal persons at Health Service Acade- tive data collection. Devolution of health has provid- my Islamabad in March 2021. The scope of the assign- ed financial and administrative autonomy to provinc- ment was explained to participants and their approval es but health system equity challenges still prevail. In was taken to collect the data. One of the major chal- Punjab, there are two health directorates: South Punjab lenges during data collection at the provincial level was and Central Punjab. Approval for data collection was the travel restriction for the World Bank consultants required separately from both directorates. In Sindh, due toCOVID-19. To overcome this challenge, the di- multiple health departments have been merged (for alogue was done with the MoNHSR&C and provincial example, CDC and Malaria, Infection control depart- IHR focal points and a consensus was built to nomi- ment, and Hepatitis are now one department) and the nate enumerators for data collection at the provincial role and responsibilities of each department in dealing level. A training manual for the collection of data was with health security were not clear. This merger also developed and the enumerators were trained online on resulted in a split hierarchy of the governing bodies; the data collection methods and techniques. A compre- where the Director-General of Health was positioned hensive session with each provincial enumerator was in Hyderabad while the Secretary of Health was placed conducted as a directive guide regarding the HSFA tool in Karachi. Getting approval for data collection was a and the methods to use guidelines. The data collection challenge in such a scenario. Similarly, in AJK, only one started in June 2021 and ended in October 2021. department is responsible for overseeing multiple JEE technical areas (field epidemiology, surveillance, lab training, and NHEPRN work under one department) 2.5 LIMITATIONS AND CHALLENGES and identification of health security expenditure by A series of challenges and limitations were en- area/department was not possible. In KP, there was no countered during the data collection. First, the gov- IHR focal person for the past six months, and seeking ernment financial system was not designed to identify approval for data collection was difficult. the expenditure outlays in JEE technical areas. Second, the contribution of development partners was not The cooperation of staff during data collection aligned with government budgeting and allocation pro- was not exemplary. In Balochistan challenges were cesses, which made it difficult to quantify the amount faced during data collection due to the absence or spent under each technical area. Third, there was little reluctance of relevant staff to share data even after the or no institutional memory of provincial health de- approval letter from the MoNHSR&C was received. partments on IHR; primarily, because the IHR focal persons involved during the JEE assessment or devel- opment of NAPHS were transferred to other depart- ments, and the current staff was not fully aware of the 9 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 METHODOLOGY PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 10 RESULTS 03. Results 11 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS The results of the HSFA have been organized community-based organizations. Section 3.4 examines into seven sections. Each section offers insight the macrofiscal context of the country. Section 3.5 re- into the country’s preparedness efforts. Section views the financing for health security, budgeting, and 3.1 outlines the funding for specific health securi- resource allocation; and Section 3.6 reviews resource ty action packages as defined in the JEE. Section 3.2 mobilization for health security. Section 3.7 highlights documents the status of current health security the constraints and limitations of the current planning, since 2007. Section 3.3 lists the critical stakehold- budgeting process functionality, and appropriateness ers in health security; the list was organized by gov- of coordinating mechanisms and implementation ernment departments, development partners, and arrangements. 3.1 FUNDING FOR SPECIFIC HEALTH SECURITY AREAS Pakistan’s health expenditure is intrinsically linked health expenditure is from current expenditure (68 per- to the economy of the country. Despite challenges, cent). The contribution from the development side is the economy of Pakistan has continued to maintain its only 32 percent. growth momentum above 4.0 percent every year from 2013 to 2014.5 Pakistan’s public health expenditure as Economic activity in Pakistan is expected to a percentage of GDP remained between 0.7 percent remain robust and benefit from an improved business and 1.2 percent in the last decade. In 2018-2019 it was sentiment, the China-Pakistan Economic Corridor 1.1 percent, slightly low as compared with neighbor- (CPEC), and other infrastructure initiatives. Some of ing countries like India (1.28 percent) and Sri Lanka the key macroeconomic indicators are presented in (3.9 percent).6 The major contribution to the public Table 1. 5 Ministry of Finance. Pakistan Economic Survey: 2003, 2007 and 2017 6 UNICEF (2020). Budget Brief: Health Sector—Sri Lanka 2019. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 12 RESULTS 236 13 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Table 1: Macroeconomic Indicators of Pakistan FY2016-2017 (%) FY2017-2018 (%) FY2018-2019 (%) GDP growth rate* 4.61 6.10 3.12 Population growth rate 2.075 2.056 2.066 Total revenue as % of GDP 15.40 15.10 16.30 Federal and Provincial Governments Health Expenditure as % of GDP** 1.0 1.2 1.1 Current health expenditure CHE (% of GDP)*** 2.90 3.20 3.40 Health Security Expenditure as % of GDP (at constant prices of 2015-16) 0.18 0.26 0.15 Government fiscal deficit as a share of GDP 5.80 6.50 4.90 Inflation 4.10 3.80 7 Public debt as % of GDP 67.10 72.10 70 Debt servicing (payment of principal and interest) as a share of government expenditure 39.10 38.50 41.20 Social protection as % of GDP 9.50 9.20 9.35 * Real Growth Rates of GDP at Constant Basic Prices of 2015-16, Pakistan Bureau of Statistics. https://www.pbs.gov.pk/sites/default/files/tables/national_accounts/2021-22/Table_6.pdf ** Economic Survey of Pakistan, 2020. *** The World Bank. Figure 1: Total HealthSecurity Expenditure (billion rupees) The HSFA found that Pakistan spent PKR 78.77 billion (US$440 million) on average per year on health security activities across 16 JEE technical areas during 2017-2019. Figure 1 shows the total expenditure on 54.33 health security at the federal and provincial levels 23% between 2017 and 2019. Almost 77 percent of health security expenditure (more than three-fourths) was incurred at the provincial level and one-fourth (that is, 23 percent) was incurred at the federal level. At present, there are no other reference data points 181.97 –within South Asian countries–to compare these re- 77% sults and ascertain whether the level of spending is adequate, high, or low. Health security expenditure is shared between various departments at the federal and provincial levels. Health security is not only under the mandate of the MoNHSR&C and its line departments but is Provincial Federal PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 14 RESULTS cross-cutting in nature. Therefore, the total spending Annual per capita health security expenditure also of PKR 236.3 billion (US$1.3 billion) is shared be- varied across provinces. While health security spend- tween other departments in charge of health security ing in Punjab and GB was PKR 501 (US$3.98) and including: the Ministry of Industries and Commerce, PKR 694 (US$5.52) per capita, Sindh spent only PKR Wildlife Department, Agriculture Department, and 12 (US$ .09) per capita. Health security spending per Ministry of Environment. capita in other provinces and federating areas was as follows: KPK PKR 63 (US$0.50), Balochistan PKR Health security expenditure varies across years at 130 (US$1.03), and AJK PKR 66 (US$0.36) (Figure 3). the federal and provincial levels. The yearly division of PKR 236.3 billion was PKR 65.6 billion in FY2016- Many reasons can be attributed to disparities in 2017, PKR 104 billion in FY2017-2018, and PKR 66.7 spending in JEE areas between provinces. First, the in FY2018-2019 (see Figure 2). NAPHS that assures spending in JEE priority areas at the provincial level was not implemented as planned. Figure 2: Health Security Expenditure per Year Some of the key interventions at the provincial level to raise health security financing, that is, coordination with provincial chief secretaries on the allocation of resources, periodic supervision of resource allocation for NAPHS and recruitment of necessary human re- sources were never initiated. Second, developing the 23.4 financial proposals, building an investment case, and drafting a change management strategy were crucial to raising money for health security. However, these im- portant actions were never pursued to channel domes- 11.2 tic and donor support, ensure economic and political 19.7 assistance, and assure the committed engagement of relevant stakeholders. Finally, in the absence of legisla- tion governing the share of public spending on health security, it is being financed mainly by the GOP devel- 54.2 80.6 47.1 opment budget at the federal and provincial levels. The provincial PC-1 for IHR was never approved and prov- inces had to rely on the recurrent side of the budget to finance health security activities. FY 16-17 FY 17-18 FY 18-19 Figure 3: Per Capita Health Security Expenditure Provincial Federal in PKR (annual) At the provincial level, there is a wide disparity in health security spending across JEE technical areas. During the period of the HSFA (2017-2019), Punjab spent PKR 55.1 billion (average per year) on 14 JEE technical areas, while Sindh spent only PKR 0.6 billion (average per year) covering 10 JEE technical ar- eas. Health security spending (average per year) in oth- er provinces was as follows: KPK PKR 2.2 billion (cov- ering eight JEE technical areas), Balochistan PKR 1.56 billion (covering seven JEE technical areas), GB PKR 0.83 billion (covering six JEE technical areas), and AJK PKR 0.026 billion (covering six JEE technical areas). 15 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Pakistan health security spending can be The Punjab province had the highest share in compared with other countries who have carried spending on health security areas in the last three out HSFAs including Vietnam and Indonesia. years (Figure 4). It spent PKR 165.3 billion on 15 Pakistan’s per capita healtth security expenditure JEE technical areas. The spending was divided as fol- was US$2.96 in 2017, US$3.96 in 2018, and US$2.07 lows: PKR 29.94 billion on biosafety and biosecurity, in 2019. This expenditure as percent of GDP PKR 29.983 billon on national legislation policy and fi- nancing, PKR 29.55 billion on food safety, PKR 20.35 was 0.18 percent, 0.26 percent, and 0.17 percent billion on IHR coordination, communication, and respectively. Comparing this expenditure with that of advocacy, PKR 14.45 billion on immunization, PKR Indonesia shows that it is quite substantial as 10.40 billion on the national laboratory system, PKR Indonesia’s per capital health security expenditure was 9.93 billion on reporting, PKR 9.75 billion on emer- US$1.23 (0.03 percent of GDP) in 2016, US$1.26 (0.03 gency response operations, PKR 9.48 billion on re- percent of GDP) in 2017, and US$1.11 (0.03 percent al-time surveillance, PKR 0.53 billion on preparedness, of GDP) in 2018. Vietnam also conducted the HSFA PKR 0.45 billion on medical countermeasures, PKR but it was confined to one year, that is, 2016. Their 0.28 billion on risk communication, PKR 0.28 billion health security spending was equivalent to US$1.94 on AMR, and PKR 0.14 billion on zoonotic disease. while the total health security expenditure was 0.09 Punjab province did not spend any amount on PoE percent of GDP. as this is a federal subject and most of the funding on Table 2: Health Security Expenditure across PoE is from the federal budget. Countries KP province had the second-highest spending 2016 2017 2018 2019 on JEE technical areas. It spent PKR 6.6 billion on seven JEE technical areas. The spending was divided as Per capita health security expenditure follows: PKR 5.95 billion on immunization, PKR 0.23 US$ billion on workforce development, PKR 0.20 billion on reporting, PKR 0.17 billion on preparedness, PKR 0.05 billion on national laboratory system, PKR 0.03 Pakistan - 2.96 3.96 3.07 billion on real-time surveillance, and PKR 0.01 billion on emergency response operations. KP province did not spend any amount on the other nine JEE technical Indonesia 1.23 1.26 1.11 - areas. Vietnam 1.94 - - - Balochistan spent PKR 4.76 billion on seven JEE technical areas. The division of spending was PKR Health Security 2.13 billion on immunization, PKR 0.87 billion on re- Expenditure % of GDP porting, PKR 0.85 billion on preparedness, PKR 0.06 billion on real-time surveillance, PKR 0.28 billion on Pakistan - 0.18 0.26 0.17 workforce development, PKR 0.03 billion on national laboratory system, and PKR 0.01 billion on emergency response operations. Indonesia 0.03 0.03 0.03 - Vietnam 0.09 - - - Source: Health Security Financing Assessment Vietnam, Indonesia, and Pakistan. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 16 RESULTS laboratory system, and PKR 0.04 billion on emergency Figure 4: Provincial Share in Health Spending response operations. AJK did not spend any amount on the other 12 JEE technical areas. Islamabad spent PKR 54.3 billion on health security. Islamabad had the second-highest share in spending on health security areas in the last three years. The spending was divided as follows: PKR 51.38 billion on immunization, PKR 1.63 billion on real-time surveillance, PKR 0.86 billion on the nation- al laboratory system, PKR 0.27 billion on workforce development, PKR 0.09 billion on zoonotic disease, PKR 0.07 billion on points of entry, and PKR 0.02 billion on AMR. ICT did not spend any amount on the other eight JEE technical areas. Figure 5: Ministry-wise Health Security Expenditure (billion rupees) GB spent PKR 2.59 billion on five JEE technical areas. The spending was divided as follows: PKR 1.42 billion on reporting, PKR 0.08 billion on national legis- lation policy and financing, PKR 0.23 billion on immu- nization, PKR 0.12 billion on biosafety and biosecurity, and PKR 0.01 billion on zoonotic disease. GB did not spend any amount on the other 11 JEE technical areas. Sindh spent PKR 1.80 billion on 10 JEE technical areas. The spending was divided as follows: PKR 0.51 billion on immunization, PKR 0.30 billion on national laboratory system, PKR 0.24 billion on IHR coordina- tion, communization, and advocacy, PKR 0.23 billion on real-time surveillance, PKR 0.18 billion on emergen- cy response operations, PKR 0.10 billion on reporting, PKR 0.09 billion on preparedness, PKR 0.09 billion on national legislation policy and financing, PKR 0.05 bil- lion on biosafety and biosecurity, and PKR 0.01 billion on AMR. Sindh province did not spend any amount on the other six technical JEE technical areas. The Ministry of MoNHSR&C along with the attached department has led the health security AJK spent PKR 0.81 billion on four JEE technical expenditure. After the MoNHSR&C, the agriculture areas. The spending was divided as follows: PKR 0.60 department has the highest spending on health security billion on workforce development, PKR 0.10 billion (Figure 5). on immunization, PKR 0.07 billion on the national 17 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS The Ministry of Environment has spent very little on for national laboratory systems, PKR 8.3 billion for health security. preparedness, PKR 1.1 billion for emergency response operations, and PKR. 3.6 billion for points of entry One of the main reasons for low health security spend- across the country. However, during COVID-19, Pa- ing at the provincial level has been the lack of moni- kistan’s national laboratory systems were not prepared toring activities to oversee the progress of the NAPHS. to face such a pandemic and initially lacked diagnostic Notification of Provincial IHR Task Forces was pend- capacity. Point of entry were not developed that could ing till 2021. Similarly, notification of IHR focal persons have saved the spread of disease and a preparedness in health and other sectors at the federal and provincial plan was only developed after the pandemic. levels (OneHealth Stakeholders) was not done. More- over, communication to the chief secretaries of each The HSFA helped to prioritize the JEE technical province for inter-sectoral coordination and resource areas at the federal and provincial levels. Table 3 allocation was never initiated. Finally, periodic supervi- shows that at the federal level AMR and Prepared- sion to ensure activities are implemented according to ness are still neglected JEE technical areas even after NAPHS at the provincial level was still pending. getting a very low score in JEE assessment. Out of the total health security spending at the federal level There are economic costs to not investing in 95 percent is going to immunization only. At the pro- health security. The cost of cure is fractional com- vincial level Zoonotic disease, Risk communication, pared with an investment intended to deal with the Antimicrobial Resistance, Medical Countermeasures and very same issue. Pakistan raised PKR 1.2 trillion for Personnel deployment, Workforce Development, and COVID-19, out of which PKR 190.3 billion was ear- Preparedness need prioritization. marked for emergency response. However, the same amount if invested earlier could have strengthened the IHR core capacities across the country. For example, the NAPHS identified funding gaps of PKR 7.5 billion PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 18 RESULTS Table 3: Health Security Expenditure (%) Total Health Security Spending (%) at Federal and Provincial JEE Score Provincial Federal (Average)* Zoonotic Disease 0.09 0.16 2.67 Risk Communication 0.16 0.00 2.00 Antimicrobial resistance (AMR) 0.16 0.03 1.00 Medical Countermeasures and personnel deployment 0.25 0.00 4.00 Workforce Development 0.61 0.50 2.67 Preparedness 0.90 0.00 1.00 Emergency Response Operations 5.49 0.00 2.25 Real time Surveillance 5.68 3.01 2.75 National Laboratory System 5.96 1.59 2.75 Reporting 6.88 0.00 2.00 IHR Coordination, Communication and Advocacy 11.32 0.00 3.00 Immunization 12.84 94.56 3.00 Food Safety 16.24 0.00 2.00 Biosafety and Biosecurity 16.55 0.02 2.00 National Legislation, Policy, and Financing 16.88 0.00 2.50 Points of Entry - 0.13 2.00 Total 100.0 100.0 *Avergage score based on JEE assessment 2016 19 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS 3.1.1 Sources of finance for health At the provincial level, health security is mainly financed through the regular budget (63.4 percent) vscurity expenditures and development budget (36.6 percent). Other sources like foreign aid and own sources are not used Health security is financed through differ- to fund health security activities. Although donors pro- ent sources at the federal and provincial levels. vide financial support to strengthen the JEE techni- Figure 6 shows the sources of health security spending cal areas; their support is usually off-budget and is not at the federal and provincial levels. At the federal level, reflected in the government financial system. The four different sources are used: development budget donors mostly provide program-based support, and (86.3 percent), regular budget (1.2 percent), external currently, no specific programs are running to address sources (8.6 percent), and own sources (3.8 percent). the JEE technical areas. “Own sources” refers to the implementing ministry or department that is generating the income from sell- Figure 7 shows the health security expenditure by the ing services and spending these funds on JEE techni- JEE technical areas. At the federal level, 94.5 percent cal areas. NIH, for example, provides laboratory tests expenditure was on immunization. The remaining 5.5 and charges a fee for the same; the revenue collected percent was spent on the other 15 JEE technical areas. from this service is then spent on health security areas. The share of development finance in health security is highest at the federal level because most of the PC-I is approved and implemented by the MoNHSR&C. Figure 6: Sources of Health Security Expenditures PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 20 RESULTS Almost 50 percent of health security spending at Prevention activities consume most of the health the provincial level is on a few JEE technical ar- security budget in Pakistan. Figure 8 shows the eas (Figure 7). At the provincial level, most of the health security expenditure by the JEE pillars: Prevent, health security expenditure was on national legislation/ Detect and Respond. The graphs show that Response policy (16.9 percent), followed by biosafety and biose- activities display an increasing trend in the last two curity (16.5 percent), food safety (16.2 percent), IHR years—PKR 5.1 billion in the financial year 2019 up advocacy, and coordination (11.3 percent), reporting from PKR 1.1 billion spending in 2017. Prevention and (6.9 percent), national laboratory system (6.0 percent), Detection activities have a mixed trend and the spend- real-time surveillance (5.7 percent), and emergency re- ing has fluctuated in the last three years. Pakistan spent sponse operations (5.5 percent). PKR 186.3 billion (78.8 percent) on Prevention, PKR 37.6 billion (15.9 percent) on Detection, and PKR 12.4 billion (5.24 percent) on the Response from 2017 to 2019. Figure 7: Health Security Expenditure by JEE Technical Areas (excluding Immunization) Federal Provincial 21 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Figure 8: Health Security Expenditures by the JEE Pillars PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 22 RESULTS Donors have provided on and off-budget support Immunization is the area that gets the most for health security. Total health security expendi- attention. Almost 90 percent of the spending in the ture by the Health Development Partners was PKR last three years has been on immunization programs. 80.17 billion in the last three financial years; PKR The total amount spent on immunization in the last 68.90 billion for on-budget and PKR 11.28 billion three years was PKR 119.44 billion (88.8 percent) of for off-budget support. There is a variation in this total spending on health security. Real-time surveil- expenditure, it was PKR 19.87 billion in FY2016-2017, lance is the second most important area and PKR 5.10 PKR 34.20 billion in FY2017-2018, and PKR 26.10 billion was spent on surveillance-based activities, that billion in FY2018-2019. A major contributor to health is, 3.8 percent of the total spending on health security security areas in the last three years was, WHO (PKR 51.76 activities. National Legislation Policy and Financing re- billion or 64.6 percent), followed by Islamic ceived PKR 2.85 billion, 2.1 percent of the total health Development Bank (PKR 16.00 billion or 20.0 security spending. IHR Coordination, Communication percent) and USAID (PKR 9.91 billion or 12.4 percent) and Advocacy, National Laboratory System, Workforce (Figure 9). The rest of the Health Development Partners Development, and Emergency Response Operations contributed to health in general but not to health received approximately a 1 percent share of the total security. health security spending. Figure 9: Health Security Expenditure by Health Development Partners at Federal Level 23 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 24 RESULTS 25 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 26 RESULTS 27 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS 3.2 HEALTH SECURITY ACTIVITIES IN National Legislation, Policy, and Financing PAKISTAN To regulate health security activities, Pakistan has The International Health Regulations (IHR) is issued multiple bilateral and multilateral agree- an instrument of international law that legally ments and legal documents (such as laws, ordi- binds 196 countries, including the 194 WHO the nances, Acts, notifications, PC-I, etc.).9 Table 4 Member States to provide an overarching legal summarizes the number of legal documents issued in framework.7 It defines countries’ rights and obliga- Pakistan for the JEE 19 technical areas. The food and tions in handling public health events and emergencies agriculture sector of Pakistan has the most significant that have the potential to cross borders. Pakistan, along number of legal documents, that is, a total of 60 doc- with the other WHO Member States, is a signatory to uments. In total, four laws govern the food safety is- IHR and the first country in the Eastern Mediterra- sues in Pakistan; three of them directly deal with issues nean Region to have undertaken the JEE for the IHR of food safety while one, namely, the Pakistan Stan- 2005.8 The Government of Pakistan (GoP) under the dards and Quality Control Authority Act, is indirectly overall lead of the MoNHSR&C conducted the JEE relevant to food safety. Emergencies and disaster de- from April 27 to May 6, 2016. The process included partments have six laws regarding disaster manage- comprehensive collaboration between the federal and ment, among which five are national laws and only provincial/federating areas involving both health and one is a provincial Act, namely, the KP National Di- nonhealth sectors. saster Management Act, 2012. A total of eight legal documents are available, each for the enforcement of The JEE assessment led to the development IHR and control of infectious diseases. of Pakistan’s “NAPHS” in 2017. The plan was developed through an all-inclusive, fully consultative, According to the 2016 JEE report, Pakistan has and participatory approach. The NAPHS involves sev- been assessed as having scored 5 (on a scale of 10) eral sectors that perform health security-related activi- for national legislation, policy, and financing tech- ties. However, due to a lack of continued and expanded nical areas. This score implies “developed capacity” in multisectoral communication between the federal gov- terms of the legal framework for IHR implementation. ernment and provincial authorities, Pakistan has been unable to fully implement the costed NAPHS to date. Further analyses and reviews of legal documents relating to health security have shown that sever- The summary of health security activities under the al areas of the legal framework are still lacking. JEE 19 technical areas is as follows: Respective ministries/departments are required to update their laws according to IHR requirements. GoP must conduct a legal and regulatory assessment to identify all areas for improvement to ensure a compre- hensive legal framework. 7 World Health Organization (2005). International Health Regulations. Third Edition, WHO. 8 World Health Organization (2017). “Joint External Evaluation of IHR Core Capacities of the Islamic Republic of Pakistan”, Mission Report: 27 April – 6 May 2016. 9 Planning Commission document (PC-I) is a planning tool for the development and execution of any project in government departments. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 28 RESULTS Table 4: Number of Legal Documents Issued for JEE Technical Areas Law/Penal Bill/ Strategies/ Ordinance Act Plan Total Code Order Policy National legislation, policy 1 1 2 - - - 4 and financing IHR coordination, communication, and - - - - - - - advocacy Antimicrobial resistance - - - - 2 4 6 Zoonotic diseases - 1 1 - 3 - 5 Food safety 1 12 17 27 - 3 60 Biosafety and biosecurity - - - - - 4 4 Immunization - 1 - - 2 2 5 National laboratory system - - - - - 2 2 Real-time surveillance - - 1 - - - 1 Reporting - - - - - - - Workforce development - - - - - - - Preparedness - 1 - - 1 1 3 Emergency response - 2 - - 3 1 6 operations Linking public health - - - - - - - Medical countermeasures - - - - - - - Risk communication - - - - - - - Points of entry (PoE) - - - - - - - Chemical events - - - - - - - Radiation emergencies - - - - - - - Total 2 18 21 27 11 17 96 IHR Coordination, Communication, identified as a Global Health Security Agenda (GHSA) and Advocacy participating country in 2014-2015 to achieve the vision of a world safe and secure from global health To strengthen the nationwide coordination and threats posed by infectious diseases. NIH, Islamabadis response system, Pakistan has adopted multi- the organization in Pakistan that has been designated sectoral/multidisciplinary approaches for the as the National Public Health Institute focal point for effective implementation of IHR. Pakistan was IHR and GHSA coordination for reporting and linking 29 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS to international and provincial IHR-related activities. the South Asian Association for Regional Cooperation The national focal point and provincial focal points for (SAARC) secretariat, there is regular coordination be- IHR and GHSA have also been notified in-country. tween SAARC countries on animal health.10 National and Multisectoral Task Force for IHR To ensure its commitment to the IHR and GHSA, and GHSA includes federal and provincial Director Pakistan has a coordinated, multisectoral partner- Generals Health (DGs), focal persons from federal ship approach, in close collaboration with the pro- Nonhealth ministries, and counterparts notified from vincial departments of health, other sectors, and the Provincial IHR Task Force in four major provinces. health development partners, as a global health In a devolved set-up, the coordination mechanism for safety responsibility at the national level. However, IHR activities functions through the Pakistan Health relevant stakeholders need to adopt dual institutional and Population Council (ministerial level) which in- coordinated and well-integrated mechanisms (horizon- cludes Health and Population Ministers. The Donor tal and vertical) to counter health security challenges Coordination Forum is another platform for general for future generations. The independent Oversight & coordination and communication between the health Advisory Committee (IOAC) of the WHO which vis- sector and health development partners. This forum ited the country in late 2017 particularly appreciated serves as a coordination link with the IHR Task Force Pakistan’s efforts toward IHR plan development: for IHR-related meetings. To communicate 24/7 with international and pro- “Strong country ownership, cross- vincial IHR focal points, various departments have been established at NIH to coordinate IHR government working, and engage- activities in Pakistan. These functional departments include laboratory diagnostics, vaccine and anti-sera ment of multiple sectors is key to production, food and drug quality control, research the success of JEE and National and development, and various training ventures. To establish a coordination mechanism under the One Action Plan (NAP). Pakistan Health Approach in-country, relevant authorities of Pakistan have been in the process of issuing re-notifi- could be considered a case study cation for multisectoral and multidisciplinary national IHR Task Forces. To quote an official of a provincial for excellence in high-level political Department of Health: leadership, engagement with the lo- “As far as a coordination mechanism that you are ask- cal authorities and multiple sectors, ing, I would like to say that no concrete coordination exists at the provincial level to oversee and cumulative- and ownership of the provincial ly coordinate the process for the implementation of Provincial International Health Regulation activities.” governments. It would be helpful to share best practices and learn from Pakistan has also strengthened its cross-bor- der coordination with Afghanistan for Polio and Pakistan’s experience with the Crimean–Congo Hemorrhagic Fever (CCHF) control activities. Pakistan also coordinates with Iran JEE and NAP.” to control the cross-border transmission of Tubercu- losis in ways that “avoid unnecessary interference with international traffic and trade”. Additionally, through 10 South Asian Association for Regional Cooperation (2014). Food Security Through Control of Transboundary Animal Diseases. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 30 RESULTS Antimicrobial Resistance (AMR) • AMR focal points have been designated in human health and veterinary health sectors. Notifications To ensure the reduction of the adverse impact have been issued for AMR focal points in health of inappropriate antimicrobial use on health in (NIH) and veterinary/food (NVL) sectors, includ- terms of cost, resistance, and poor outcomes in ing provincial AMR/IPC focal points in the veter- both the human and veterinary sectors, agricul- inary sector. ture, finance, environment, and consumers, the • The AMR surveillance network has been extended Government of Pakistan has already taken several to 25 laboratories across the country. initiatives to address AMR. AMR was recommend- • The Global Antimicrobial Resistance Surveillance ed as one of the priority areas for action in the JEE System (GLASS) Pakistan has been developed to report because of its low score against four AMR in- support the Global Action Plan on Antimicrobial dicators. The results of the JEE further reiterated the Resistance to establish a standardized, compara- need and endorsed the parallel process of developing ble, and validated data collection system on AMR, a National Strategic Framework for Containment of informed decision-making for local, national, and AMR. In the process, several other health development regional actions, and provide an evidence base for partners and professional organizations also indicated action and advocacy on AMR.11 their interest and joined the ongoing AMR activities • An integrated AMR surveillance system under the in Pakistan. The MoNHSR&C is working with the One Health approach (ESBL Tricyclic project) has provinces, veterinary sector, and health development been established. partners to build national capacity in strengthening- • Sentinel sites for AMR detection and surveillance surveillance and laboratory diagnostics, promoting are being implemented in two provinces. rational use of antimicrobials and infection prevention and control, and educating communities in the preven- Despite laudable efforts by GoP to improve AMR’s tion and control of antimicrobial resistance. Pakistan technical expertise, AMR has been spreading at continues to work closely with donor partners in the an alarming rate. There is a nationwide shortage of development and implementation of the country’s qualified infection control experts, infectious diseases AMR plan. specialists, and medical microbiologists. Programsfrom AMR surveillance and prevention are limited to a few In the context of the JEE assessment done in tertiary areas and university hospitals of Pakistan. 2015, there has been continued progress toward developing AMR capacity to respond to the Even though many elements of AMR surveillance challenges posed by AMR. exist, additional efforts are required to enhance Pakistan’s score of AMR under JEE. Strengthening • Commitment to combat AMR has been strength- the infrastructure of diagnostic laboratories in public ened by the National Multisectoral and Multi- and animal health sectors and nationwide extension disciplinary Steering Oversight Committee for of AMR surveillance to monitor and control the use AMR under the leadership of the MoNHSR&C. of antibiotics in human and animal sectors would be The existing National AMR Strategic Frame- a significant step. Government should recognize the work has evolved into an AMR National Ac- importance of the One Health approach and strength- tion Plan (NAP), with involvement and full par- en coordination between health and nonhealth sectors ticipation of the health, veterinary, agriculture, to address the issue of AMR. According to an official and other sectors at the federal, provincial, and from NIH: regional levels under the One Health approach. 11 National Institute of Health, Islamabad, Pakistan. Pakistan Antimicrobial Resistance Surveillance System Report, 2017-18. 31 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS • Effective strategic frameworks and action plans at the national and provincial levels are crucial to di- “AMR is a cross-cutting area, it’s minish the risk and minimize the impact of infec- not only health sector, but animal tious zoonotic diseases. • As part of its commitment to prevent zoonotic and environment sector, it’s quite a diseases, the MoNHSR&C is in the process of developing a National Strategic Framework for broad area, for that we do have the Zoonotic Disease, National Action Plan 2023 for Rabies Control, and National Strategic Framework involvement of the Pharmaceutical for Brucellosis and Rabies in collaboration with association, poultry association. CDC. • Antibiotic sensitivity testing (AST) is being con- ducted on both sick and healthy animals. • A CCHF Task Force has been notified in Ba- lochistan where there is significant cross-border movement of animals. Zoonotic Disease While Pakistan continues its efforts at the national Pakistan enunciated a multidisciplinary technique and provincial levels to fill existing gaps in knowl- to deal with zoonotic diseases by strengthening a edge and issues associated with the origin and large stake of medical and veterinary health agen- transmission of many zoonotic infections, much cies in disease surveillance and control activities. greater cooperation is needed to protect the health of The multi-sectoral collaboration took place with ded- the people from the risk of all types of zoonotic infec- icated planning and well-exercised coordination of tions. The Department of Animal Quarantine in the activities. To address and identify zoonotic diseases country is responsible for countering the threats posed of greatest national concern for Pakistan, various ini- by zoonotic diseases. However, its role is limited due tiatives have been taken involving representatives of to some structural and functional issues. There is no human health, livestock, environment, wildlife, re- mechanism for a coordinated response to outbreaks of search, and higher education sectors. zoonotic diseases at the national and provincial levels. The Government of Pakistan is in the process The activities for control of zoonotic infections of implementing the International Health Reg- should be based on the concept of “One Health”. ulations (IHR) five-year country roadmap to This approach is defined as a common coordination prevent the transmission of zoonotic diseases to mechanism, joint planning, joint implementation, com- the human population. Representatives from hu- munity participation, capacity building, and joint mon- man, animal, and environmental health sectors have itoring and evaluation framework between the animal been enlisted to develop a strategic framework to pri- health and human health sector. This concept could be oritize endemic and emerging zoonotic diseases by boosted by implementing necessary legal instruments adopting a One Health approach. A joint One Health and mechanisms. Zoonotic Disease Prioritization (OHZDP) and a One Health Systems Mapping and Analysis Resource Food Safety Toolkit (OHSMART™) workshop was organized in collaboration with various government sectors and Over the past two decades, the Government international stakeholders in 2017. The MoNHSR&C of Pakistan has recorded significant prog- has prioritized six zoonotic diseases for surveillance ress in the food safety area with mixed results. and rapid response in Pakistan (Zoonotic Influen- Though food safety is the responsibility of multiple za, Brucellosis, Salmonella, Rabies, Crimean-Congo ministries at the federal level, the MoNFSR is mainly Hemorrhagic Fever, and Anthrax). responsible for policy formulation, economic PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 32 RESULTS coordination, and planning in respect of food grain Pakistan has an established mechanism at the and agriculture. Pakistan aims to achieve food safety, national and provincial levels with multisectoral food security and nutrition goals through sustainable collaboration to investigate food-borne outbreaks development of the agriculture sector. In Pakistan, pro- and food safety-related emergencies. In provinces, vincial governments are responsible for establishing in- food safety testing laboratories in provincial preventive dependent Food Safety Authorities to develop and en- medicine centers or testing centers are responsible for force food safety standards for domestically produced food safety testing. foods.12 A cross-sectoral approach connecting agricul- ture, food security, climate change, and market services Some of the food safety assurance activities are as results in enhanced coordination. Table 5 shows orga- follows: nizations that are attached to the MoNFS&R in certain JEE technical areas. • Industries have voluntarily opted for certification to protect their businesses or exports as the food safety emergency response system does exist at the Table 5: Organizations Attached to the Ministry industrial level. These industries are affiliated with of National Food Security and Research accreditation bodies/ affiliated certifying agencies. • Activated project-based coordination mechanisms 1. Agriculture Policy 2. Department of Plant exist, for example, projects on Poultry influenza, Institute (API) Protection (DPP) Foot and Mouth Disease (FMD). 3. Federal Seed 4. Animal Quarantine Certification Department (AQD) The National Agriculture Research Center (NARC) is and Registration the largest research Center under PARC that serves as Department a common platform for scientists working in different 5. National Veterinary 6. Pakistan Agricultural federal, provincial agricultural research, and academic Lab (NVL) Research Council institutions to mutually plan their research activities, (PARC) avoiding unnecessary duplication of research efforts. 7. Pakistan Agricultural 8. Federal Water Storage and Services Management Cell Corporation (FWM) • PARC has cross-border coordination with Afghan- (PASSCO) istan and with the SAARC countries. • Regarding activities performed to support JEE 9. Livestock and Dairy 10. Pakistan Oilseed Development Board Development Board technical areas, PARC is working on infectious (LDDB) (PODB) diseases in poultry, infectious and other contagious diseases in the animal sector for zoonotic diseases. 11. Fisheries 12. Livestock Wing The center also focuses on AMR, Influenza, and Development Board (FDB) Brucellosis. 13. Economic Wing 14. Pension Cell Despite the advances in food items processing and 15. Focal Person 16. Public Complaints production technology, food safety remains an un- Under the Freedom Cell achieved goal in most countries of the world in- of Information cluding Pakistan, and is a matter of great concern. Ordinance, 2002 Presently, there exists no precise and integrated system 17. Pakistan Central Cotton 18. National Fertilizer of monitoring and surveillance to mitigate health and Committee (PCCC) Development Center economic losses associated with a substandard food (NFDC) safety system in Pakistan. Coordination of food safety 12 World Food Programme (2019). Pakistan Overview of Food Security and Nutrition—Improving Access to Food. WFP. 33 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS standards and response capacity for food-borne emer- Disease has an accredited facility with biocontain- gencies vary across the country. ment and controlled access. • A functional biosafety level (BSL-3) laboratory Effective communication and collaboration among exists at the national level. various sectors responsible for food safety are required. The country needs to bring about certain Although Pakistan has made remarkable efforts in radical legislative changes to ensure that safe food promoting a culture of biosafety and biosecurity, reaches everyone without bearing any kind of addition- several constraints persist related to sustainable al cost. A harmonized consistency is needed among development and the expansion of the biosecurity provinces in the context of food safety control man- capacity in Pakistan. A systemic inventory of bio- agement. According to an official at MoNFS&R: hazards to maintain and control biohazard materials is lacking. There is no comprehensive biosecurity and “If only 30 percent-40 percent implementation of co- biosafety program at the federal and provincial levels. ordination activities were done, it will change the sce- nario; currently, there are issues with scheduled meet- To meet the demand for diagnostics and research ings and coordination is an issue.” for human, animal health, food, and environmen- tal safety, Pakistan needs reliable and safe labora- Biosafety and Biosecurity torycapacity. The laboratories handle potentially haz- ardous biological materials and therefore, a dire need One of the core capacities for IHR implementa- for guidance and capacity building of staff is essential tion is strengthening laboratory services which are to ensure safe and secure operations. considered as a vital component of the health care delivery system of the country. Immunization • Biosafety and biosecurity are considered Pakistan has a functioning nationwide vaccine fundamental components of laboratory delivery system with effective distribution and quality management systems. In 2015, a ongoing quality control. Ever since its inception in National Laboratory Working Group (NLWG) 1978, the Expanded Program on Immunization (EPI) was notified by the MoNHSR&C which in Pakistan protects against ten vaccine-preventable carried out assessments of public and private sector diseases and immunizes children below 23 months laboratories with the support of development of age. National coverage of fully vaccinated children partners.13 (0-9 months) is 76.4 percent.14 The program was im- • Laboratory analysis encompasses clinical plemented under the MoNHSR&C until July 11, 2011 diagnostics, the National TB Program, veterinary when Amendment 18 to the Constitution devolved services, and academia at both national and provincial health completely to the provinces. levels. • In 2005, Pakistan biosafety rules were notified. Devolution led to many changes in the • In 2017, Pakistan formulated the National national immunization program. After devolution, Biosafety & Biosecurity Policy covering all labora- a Federal EPI cell under the MoNHSR&C includ- tories from health, nonhealth, research, and devel- ing the federally administered Territories and four opment, that was a fundamental step in ensuring Provincial EPI cells were established in the Directorate that laboratory practices were carried out safely General Health Services (DGHS) in each province. and securely. • The National Reference Laboratory for Poultry The EPI at provincial level (Balochistan, Khyber 13 National Institute of Health. (2017). National Laboratory Biosafety & Biosecurity Policy, Islamic Republic of Pakistan. 14 Survey Report, The Third Party Verification Immunization Coverage Survey (2021). PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 34 RESULTS Pakhtunkhwa, Punjab, Sindh) and areas (Azad Jam- full immunization coverage; this can only be achieved mu & Kashmir, Gilgit Baltistan, and ICT) have Pro- by closing knowledge gaps, ensuring that all popula- vincial /Area EPI cells under respective Departments tions (regardless of socioeconomic status) have access of Health and are managed by Provincial/Area EPI to quality services, and instituting sustainable solutions. managers and other staff. Currently, the EPI is man- Although the current progress to enhance immuniza- aged and implemented through interprovincial coordi- tions services has a good score in JEE assessment, Pa- nation provided by the provincial-level ministry. The kistan still believes that EPI program managers need to National Immunization Technical Advisory Groups seek solutions specific to provincial disease trends and (NITAGs)—multidisciplinary groups of national ex- predictors to boost coverage. According to a provincial perts—are responsible for providing independent, ev- EPI focal person: idence-informed advice to policy makers and program managers on policy issues related to immunization and “The main strengths of our program are, very low vaccines. staff turnover of vaccinators, wide presence across the province, infrastructure (wherever EPI Centers are Pakistan has recognized that the most important available), a developed service delivery strategy but that and cost-effective strategy in any health program it is not implemented well is another story.” is to provide immunization for the control and pre- vention of vaccine-preventable diseases, and has taken many significant steps in this direction. National Laboratory System Pakistan has developed some laboratories with ex- • Development of effective vaccine manage- cellent capabilities. The two dedicated public health ment-improvement plans and their implementa- laboratories in Pakistan are the Public Health Labora- tion. tories Division (PHLD) at the NIH Islamabad (referral • Centralized procurement of vaccines and lab) and the Microbiology Lab of the Institute of Pub- logistics in the post devolution scenario inactivated lic Health (IPH), Lahore. PHLD offers laboratory sup- the polio vaccine introduced all over the country as port to public and private sectors on timely detection, a part of the endgame polio strategy along with the prevention, and control of infectious diseases during switch to the oral polio vaccine. outbreaks and epidemics. • National introduction of the rotavirus vaccine. • Improvement in vaccine management through Realizing the importance of laboratory services, nationwide scale-up and use of the Vaccine Pakistan has focused on strengthening the labora- Logistics Management Information System tory system across the country through a systemic (VLMIS). approach. • Vaccine audit at federal and provincial levels for GAVI-supported vaccines. • The division has installed eight lab-based Influenza Surveillance lookout sites Pakistan is committed to increasing routine in Islamabad, Lahore, Karachi, immunization coverage and equitable access to Peshawar, Multan, Quetta, Gilgit and immunization services across the country. The Muzaffarabad (AJ&K) for influenza surveillance Government of Pakistan aspires to reach 90 percent and diagnostic services. 35 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS • For annual flu vaccine composition influenza remain areas for improvement through technical strains are also being provided for the region. The support and refresher training. Pakistan needs to trends are regularly reported at the website main- highlight the importance of having effective communi- tained by WHO. cation and coordination mechanisms in place for shar- • PHLD houses one of the six Regional Reference ing information, as well as the need for the national, Laboratories for Poliomyelitis. provincial, and district health authorities to work to- • The transportation of samples for polio diagnosis gether when responding to outbreaks. is well established. • With technical assistance from international part- Real-Time Surveillance (IDSR) ners, the PHLD also executes lab-based surveil- lance programs on Human-Avian-Swine Influenza Although Pakistan is in the process of strength- and Bacterial Meningitis. ening IDSR, there is a need to verify the alerts for • Routine and specialized laboratory services for early detection and response activities by IDSR public health issues are delivered by lab divisions teams and other concerns in their respective of the apex national reference public health lab- provinces and areas. oratory in Pakistan for communicable diseases in- cluding Dengue, Avian Influenza, CCHF, SARS, Several infectious disease surveillance systems Hepatitis, HIV/AIDS and Polio, Measles, etc. operate in Pakistan, in both the human health and • NVL is the national reference lab of Pakistan livestock health sectors. The Epidemic Investigation which deals with the livestock diseases of animals Cell (EIC) at NIH has been established to respond to (cattle, buffalo, sheep, and goat) diseases like peste alerts/outbreaks and epidemics, and national and inter- des petits ruminants (PPR), foot and mouth dis- national events of public health significance. The unit ease (FMD), and some the zoonotic disease like is also responsible for providing the required feedback Rabies, Brucellosis, etc. The working of NLV to the concerned stakeholders. This cell gathers disease is being examined by the Animal Husbandry surveillance data from relevant available sources and Commission (AHC). periodically disseminates the epidemiological informa- • NVL being an independent entity at the federal tion to stakeholders. The need for Information dissem- level is the main stakeholder for lab strengthening ination is to identify/notify high-priority communica- and other monitoring activities and also has linkag- ble and noncommunicable diseases of public health es with other provinces. Provinces are responsible concern for event-based surveillance. The division for activities like lab diagnosis, disease surveillance, generates a weekly bulletin on IDSR on national and and vaccination. provincial indicators (ILI, Acute Diarrhea-non cholera, • For testing purposes, provincial veterinary labs Malaria, ALRI < 5 years, SARI, Typhoid, TB, Measles, have been developed. Chickenpox) in the provinces. Cases of chickenpox re- • At the provincial level, regular refresher courses ported more from Sindh need to be verified, investi- and on-spot training are being conducted. gated, and responded to. Acute viral hemorrhagic fever • Provincial lab results are regularly shared with cases were reported more from Balochistan and Sindh. NVL, and coordinated with the federal labs on na- This needs verification, outbreak investigation, and tional issues like control programs, etc. response activities at the earliest. Maximum Typhoid cases were reported from Balochistan, KP, Sindh, Overall, mitigation plans are in place to detect out- and GB that need detailed investigation and classifi- breaks and to collect and transport specimens to cation (that is, MDR or XDR) followed by response enable timely laboratory testing. However, there activities. Malaria cases were reported more from PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 36 RESULTS Balochistan, KP, and Sindh. Verification, epidemiolog- sourced and under-financed to deal with the mandate ical investigation, and response action are urgently re- of health emergency. Where there was an established quired. Enhancement of community awareness on wa- set up for NDMA at the federal and provincial levels, ter, sanitation, and hygiene (WASH) practices especially NHEPRN remained a subordinate office of MoNHS- for diarrheal diseases and typhoid affected districts is R&C with limited presence at the provincial level. specifically needed. Health emergency preparedness in Pakistan en- compasses all measures taken before a disaster Preparedness and Emergency or severe event that are aimed at minimizing loss Response Operations of life, disruption of critical services, and dam- age when the disaster occurs. Till 2005, the reactive Pakistan is one of the most vulnerable coun- emergency response approach in the form of the Ca- tries in the world to natural disasters including lamity Act of 1958 remained the fundamental way of floods, earthquakes, tsunamis, cyclones, drought, coping with disasters in Pakistan. The Earthquake in avalanches, and glacial lake outburst floods. Floods 2005 highlighted the need for a paradigm shift from and earthquakes are major recurrent disasters that have the response and relief-oriented approach to mitiga- caused huge losses to life and property, badly impacted tion and preparedness. It additionally demonstrated the livelihoods of vulnerable groups including women, the need for establishing appropriate policy andinsti- children, the elderly, and the disabled in underdevel- tutional mechanisms to reduce losses from disasters in oped areas. the future. The need was fulfilled through the prom- ulgation of the National Disaster Management Act in At the national level, the National Disaster Man- 2010. As a result, a network of disaster management agement Commission (NDMC) is headed by the institutions came into being throughout the country. Prime Minister as the Chairperson. The NDMC The NDMA at the federal level is working as a focal is the highest policy and decision-making body for point to lead the process by facilitating the work of disaster management. At the provincial level, there Provincial Disaster Management Authorities (PDMAs) is a Provincial Disaster Management Commission and the District Disaster Management Authorities (PDMC) which is chaired by the Chief Minister. The (DDMAs) (Figure 10). Chief Minister has the power to nominate other mem- bers of PDMC. At the district level, there are district The new system envisages attaining disaster management authorities (DDMAs) which sustainable social, economic, and environmental are headed by District Nazims whereas DCs, District development in Pakistan through reducing risks and Police Officers (DPOs), EDOs (Health), and any vulnerabilities. Its mission is to improve institutional other district-level officers appointed by the District capacities for disaster preparedness, response, and re- Government are its members.15 covery with a risk reduction perspective in the develop- ment planning process at all levels. In Pakistan, NHEPRN is responsible for coor- dinating all aspects of health-related emergency Pakistan needs to enhance preparedness and re- management including Preparedness, Response sponse mechanisms at PoEs to identify possi- and Recovery. NHEPRN was established to deal ble innovative and cost-effective solutions and to with health emergencies. NHEPRN came into being develop intersectoral and interdepartmental coor- in March 2010 by separating the emergency cells at dination mechanisms for more effective PoE man- MoNHSR&C to perform functions of health carepre- agement. There is a dire need to enhance capacity paredness, response, and recovery in disaster situations. building for skills development for efficient response However, after its establishment the funds released to to public health events (Figure 11). Development oversee preparedness activities were limited. The HSFA of guidelines and SOPs must be pursued at all PoEs showed that besides getting salaries and some oper- about the management of -infectious diseases and food ational expenditure, NHEPRN remained under-re- safety. 15 Designation of a Governor of a province. 37 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Figure 10: NDMA Structure PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 38 RESULTS Figure 11: IHR Implementation at Points of Entry IHR Implementation of Points of Entry “PAKISTAN STANDS IN THE GLOBAL COMMUNITY AS A COUNTRY SAFE AND FREE FROM CROSS-BORDER TRANSMISSION OF COMMUNICABLE DISEASES AND HEALTH HAZARDS.” —Directorate of Central Health Establishments (DoCHE) 39 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Pakistan’s experiences with COVID-19 Real-time surveillance: The Field Epidemiology & Disease Surveillance Division (FE&DSD)” was insti- The first case of COVID-19 was reported on tuted to collect and examine disease surveillance data. 26 February 2020, and the spread of the pandem- FE&DSD initiated the lab-based surveillance testing, ic was low compared to neighboring countries. This targeting the E-gene of coronavirus SARS-CoV-2 by low spread of disease was mainly attributed to Paki- practicing the WHO Protocols for COVID-19 testing. stan’s timely measures. Various pharmaceutical and non-pharmaceutical measures have helped Pakistan to Workforce development: MoNHSR&C also initiat- curtail the exponential spread of the disease. ed a training program with the help of its line depart- ments. The polio eradication cell was transformed into Pakistan’s early preventive measures included relevant a COVID-19 response cell at EPI. A series of train- policy decisions, instituting coordination arrangements, ing was given to the call center staff dealing with the and initiating communication and advocacy efforts. helpline 1166. Moreover, MoHSR&C also launched an Further, urgent expansion and enhancement of sur- awareness-building campaign, “WE CARE,” to train veillance and laboratory diagnostic capacities helped to 100,000 health workers on infection, prevention, and detect the pandemic’s magnitude on time. Additionally, control (IPC) protocols. the rapid development of isolation centers and quar- antine facilities has favored the response framework. Preparedness: Pakistan’s Preparedness and Response These interventions aided the GoP in reducing the dis- Plan (PPRP) was developed in April 2020 to outline ease burden in the country. The National Command the preparedness and response activities. The plan and Control Centre (NCOC) was established to har- was devised in line with the National Action Plan for monize the operational response to COVID-19 at the COVID-19 (NAPC) and guided by the WHO Strategic federal and provincial levels. Preparedness and Response Plan (SPRP). Some of the measures in the context of IHR were as Points of entry: Pakistan took different measures to follows: stop the spread of disease. Isolation wards were desig- nated at the federal and provincial levels, some hospi- National legislation, policy, and financing: The first tals were converted to quarantine facilities, and various draft of new legislation, “National Health Emergency facilities at the federal and provincial levels were also Response Act, 2020,” was developed to minimize the earmarked as quarantine facilities. By June 2020, a total impact of an emergency on the loss of life and prop- of 36 hospitals were assigned to deal with COVID-19 erty and reduce the risks associated with the disease. patients. Further 23,557 quarantine sites were made available in 139 districts across Pakistan. A total of 139 IHR coordination, communication, and advocacy: quarantine facilities were made functional in different The National Command and Control Centre (NCOC) provinces including Islamabad (2), Baluchistan (10), was established to harmonize the operational response KPK (52), Punjab (6), Sindh (2), GB (63), and AJK (4). to COVID-19 at the federal and provincial levels. National laboratory system: At NIH, the National Influenza Center was the first laboratory in the country to acquire the diagnostic capacity for COVID-19 and initiated testing on February 1, 2020. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 40 RESULTS 3.3 STAKEHOLDER MAPPING managed at the federal and provincial levels. The fed- eral-level ministries and departments collectively look This section is divided into two parts. Part I at 13 JEE technical areas. The province of Punjab is explains the stakeholder mapping at the federal and currently working on 14 JEE technical areas followed provincial levels. Part II explains the functionality and by Sindh (10 JEE technical areas), KP (8 JEE tech- appropriateness of coordinating mechanisms, and the nical areas), Balochistan (7 JEE technical areas), and mechanics of coordination during emergencies. AJK and GB (6 JEE technical areas each). It is worth mentioning here that even after the devolution PoE re- The MoNHSR&C is the government agency re- mained under the federal ministry hence none of the sponsible for the health system at the federal lev- provinces shared any data regarding this JEE area. el along with its provincial counterparts. The 18th Amendment to the Constitution devolved health sub- One or many departments are working at the fed- jects to provinces in June 2011. Thus, the health min- eral and provincial levels on JEE technical areas. istry transferred most of the programs run by them to The data gathering revealed that a total of 83 depart- provincial health departments. The MoNHSR&C was ments have been working across Pakistan to implement reconstituted in 2013 with defined roles and respon- IHR core capacities. Few of the departments have been sibilities as per the Constitution. Similarly, each prov- working in all provinces like expanded programs on im- ince stands responsible for controlling, managing, and munization but because of provincial autonomy, each administering medical service matters to the citizenry province has assigned JEE technical areas to different of their jurisdiction including IHR. Further, each prov- departments. At the federal level, 11 departments have ince frames and enforces health policies in its province been working to implement IHR core capacities. At the in line with the federal health department. The respec- provincial level, multiple departments are working on tive secretariats govern each provincial health depart- JEE technical areas. In Punjab, for example, 13 depart- ment under the supervision of a health minister of that ments are looking for JEE technical areas, while in KP province, controlled by a secretary, additional secretar- 15, Sindh 11, GB 16, AJK 12, and in Balochistan 5 ies, deputy secretaries, and a Director General Health departments are working on the JEE technical areas Services, assisted by a director and deputy directors. (Figures 12 and 13). Annex 1 provides the complete list of departments. Each province has been working on selected JEE technical areas as per their priorities. In the con- text of IHR 19 technical areas, the MoNHSR&C, along with its attached departments and other ministries in- cluding MoCC, and MoNFSR, has been working to strengthen IHR implementation at the federal level. At the provincial level, each province has been working on one or many health securities activities. Figures 12 and 13 show the overview of the health security activities 41 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Figure 12: JEE Technical Areas Covered at the Federal and Provincial Levels Punjab Singh KP Balochistan AJK GB Federal Donor National Legislation, Policy, and Financing IHR Coordination, Comm & Advocacy Antimacrobial Resistance (AMR) Zoonotic Disease Food Safety Biosafety and Biosecurity Immunization National Laboratory System Real-Time Surveillance Reporting Workforce Development Preparedness Emergency Response Operations Medical Countermeasures Risk Communication Point of Entry PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 42 RESULTS Figure 13: Number of JEE Technical Areas Covered at Federal and Provincial Levels Engagement of civil society, CBOs, and the pri- is lacking. Agha Khan University Hospital (AKUH) has vate sector in health security activities is limited been working in AMR and IPC, but such initiatives’ and confined to AMR, Immunization, and IPC-re- scope and scale are limited. Similarly, Shifa Interna- lated work. Government notification is a mechanism tional Hospital and Shaukat Khanum Hospital work through which stakeholders are taken on board and in health, but they are more at the clinical set-up and briefed about their roles and responsibilities to over- research-based work. During the dengue outbreak, the see and coordinate IHR implementation. The first IHR private sector also reported some involvement in re- notification on June 13, 2014, laid the foundation for porting the dengue cases from Punjab and KP. developing the structure necessary for implementing IHR; however, the notification did not address the Health development partners have been actively role of civil society, community-based organizations participating in IHR implementation and were (CBOs), and the private sector in implementing IHR. part of the JEE assessment. The MoNHSR&C has Further, some of the IHR areas being sensitive like initiated numerous initiatives to prepare and stream- chemical events, radiation emergencies, and biosafety line the processes for conducting JEE. These steps and biosecurity make it difficult for CBOs and other include the formulation of a country planning team private organizations to take an active part in the IHR and stakeholder mapping. For the stakeholder map- implementation process. As a consequence, there has ping, provincial and regional stakeholders from health been limited involvement of CBOs and civil society and other sectors such as agriculture and environment, to date. However, the EPI program of the MoNHS- etc. were involved (Figure 14). In the NAPHS, all po- R&C has attracted CBOs to help in providing access tential and relevant stakeholders were engaged for to better health and immunization services for chil- specific JEE technical areas. The list of all key stake- dren. Some sporadic work is being done in the private holders at the national, provincial, and international sector, but it is not aligned with any government plan level that were part of the JEE assessment and are or requirements. The private sector contributes to the now participating in health security areas is given in health sector, but its representation at the policy level Annex 1. 43 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Figure 14: Stakeholder Mapping by Provinces and JEE Technical Areas Punjab Sindh KP Balochistan AJK GB Federal ICP National Legislation, AGD RS L&J MOCC Policy and Financing L&D HCP IHR Coordination, ICP AGD RS Comm. & Advocacy ADP PARC NVL Antimicrobial Resistance ICP AGD PPC LSDH NARC (AMR) AHC P&W PARC NARC ACP MCP Zoonotic Disease LSDA AHC AGD L&D PARC Food Safety MCP L&D MCP EPA AHC Biosafety and Biosecurity HCP AGD TBC FRD EPA EPI EPI EPI EPI TBC TBC EPI EPI EPI MNCH FOD Immunization PD ACP TBC ACP NARC EPI IDSR MCP National Laboratory MCP HCP PHL AHC MNCH MCP TBC ICP L&D NIH System TBC MCP TBC MCP TBC HCP ACP ACP HCP TBC NPF NIH ICP MCP L&D MCP ADP LHW Real-Time Surveillance MNCH TBC HCP MCP IRMNCH MCP MNCH MNCH FP&PHC MNCH MCP MCP LHW MCP LHW NP LHW Reporting HCP ICP ACP MOCC TBC MNCH NHEPRN LHW IDSR MCP LHW HAS MNCH CHE Workforce Development LHW ACP MCP CDC MNCH MNCH P&C NHEPRN Preparedness HCP LHW LHW NPC FES TBC ACP CDC MCP Emergency Response ACP TBC FEL NHEPRN IRMNH HCP TBC NHEP & RN Operations P&C Medical Counter- TBC HCP measures Risk Communication ACP ENA Point of Entry CHE Note: Malaria Control Program (MCP), Expanded Program on Immunization (EPI), Public Health laboratory (PHL), Field Epidemiology & Surveillance (FES), Field Epidemiology Lab Training (FEL), National Health Emergency Preparedness & Response Network (NHEP&RN), Law and Joviallyn (L&J), Livestock Department PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 44 RESULTS (Human) (LSDH), Livestock Department (Animal) (LSDA), Parks and Wildlife Circle (P&W), Environment Protection Agency (EPA), Fisheries Department (FRD), Forest Department (FOD), National Program for FP- PHC (NPF), Infection Control Program (ICP), Agriculture Department Punjab (AGD), Livestock & Dairy De- velopment (L&D), Center of Disease Control (CDC), AIDs Control Program (ACP), Hepatitis Control Program (HCP), Tuberculosis Control Program (TBC), Environment Department Punjab (ENA), Lady Health Worker (LHW), National Program for Prevention & Control (PPC), National Program for Prevention & Control of Blindness (NPP), Polio Department (PD), Regular Scheme (RS), Annual Development Plan (ADP), Pakistan Agriculture Research Council (PARC), National Veterinary Laboratory (NVL), National Agriculture Research Center (NARC), Animal Husbandry Commission (AHC), Fisheries Department (FRD), Maternal, Newborn, Child, Health (MNCH), Integrated Disease Surveillance and Response (IDSR), Public Health Laboratory (PHL), National Institute of Health (NIH), Integrated Reproductive, Maternal, Newborn, Child, Health (IRMNCH), National Program (NP), Ministry of Climate Change (MOCC), Health Services Academy (HSA), Central Health Establishment (CHE), Prevention and Control (P&C), National Program Center (NPC). 45 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Various coordination mechanisms exist along- first IHR Task Force was limited to addressing ten IHR side working groups and task forces to deal with core capacities.17 In 2016 the MoNHSR&C re-notified issues of health. First, is the Parliamentary Standing the IHR Task Force and invited development partners Committee. The Committee has an overarching role to implement IHR. The first national IHR Task Force to monitor the progress of the health sector, includ- meeting was held on February 20, 2018, in Islamabad. ing MoNHSR&C. The 23rd coordination meeting was Annex 2 and Annex 3 show the notification of the held on April 19, 2021, at MoNHSR&C to discuss the National IHR Task Force. progress on the reorganization of NIH and discuss the federal medical teaching institute bill, etc. The meeting No formal donor coordination mechanism exists notices and other relevant information is available on for IHR implementation besides the IHR Task the website of the National Assembly of Pakistan.16 Force. WHO established the Health, Population, and Second, is Inter-Ministerial Pakistan Health & Popu- Nutrition Development Partners Group (HPNDPG) lation Strategic Forum (PHPSF). This is the main fo- in 2014 which aims to coordinate health, population, rum at the ministerial level that links the MoNHSR&C, and nutrition programs with GoP. However, rais- provincial health departments, and Population Welfare ing IHR-related issues is beyond the mandate of the Department (PWD). It is a strategic level forum that HPNDPG forum. promotes the policy dialogue to improve health and population outcomes in Pakistan. This forum was es- An EPI steering committee at the provincial lev- tablished in 2014 and addressed strategic level issues el meets monthly to discuss the progress of EPI to achieve the National Health Vision 2016-2025, Na- departments that have strengthened and developed tional Vision 2016-2025 for Coordinated Priority Ac- the provincial capacity to deliver EPI services in their tions, GHSA, SDG3-UHC, and other like visions and respective provinces. agendas. Overall, there is a lack of coordination between The Pakistan Health and Population Interagency the federal, provincial, and local governments Coordination Consortium is the third coordina- and other relevant stakeholders regarding IHR. tion mechanism that brings together government Due to the nonexistence of the provincial IHR Task entities and development parners. The secretary of Force, there is no active provincial or interprovincial MoNHSR&C chairs this forum. The representation coordination mechanism for health security. Lack of from development partners ensures formal discourse resources, political will, and/or other issues are not the on strategic and programmatic issues. The forum only cause. Provincial actors working on different IHR aims to enhance the coordination of development areas are not well oriented and vigilant about IHR sub- assistance with national priorities and systems. Further, jects and the need to ensure that health security issues it promotes results-oriented M&E systems to enhance are being addressed at the provincial level. mutual accountabilities. Established in 2014, the IHR Task Force is the Coordination during a public health coordination mechanism to oversee the imple- emergency mentation progress for IHR core capacities across Pakistan. The departments that are part of the Task In the last couple of decades, Pakistan has encoun- Force include food security, Ministry of commerce, tered major natural calamities in the form of earth- education, interior, Strategic Plans Division, and Gen- quakes and floods that have left millions of people eral Headquarters (GHQ). However, the scope of the homeless, facing economic constraints, and in a state 16 See details at http://www.na.gov.pk/en/notices.php 17 These areas include (i) National legislation, policy and financing, (ii) Focal points communications, (iii) Surveillance, (iv) Response, (v) Preparedness, (vi) Risk communication, (vii) Human resources, (viii) Laboratory, (ix) Potential hazards, and (x) Points of entry. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 46 RESULTS of public health emergencies. These problems often 10 years. The plan was devised in consultation with get aggravated as the health delivery system is not ro- all the relevant stakeholders at the national and pro- bust enough to respond to natural disasters. Hence, the vincial levels, keeping in view the seven fundamental need to address disaster risk management was always principles of SDFRR. One limitation of SFDRR was felt in the country. Pakistan has gone through various it does not address all the 19 core areas of health secu- phases before establishing a formal authority to lead rity pointed out in the JEE, especially AMR, biosafety, the disaster risk management efforts in the country. national laboratory system, real-time surveillance, and chemical events. NDMA was established on May 30, 2005, to lead disaster risk management in the country. NDMA is Besides SFDRR, every province has a civil act that a federal-level entity comprising PDMAs and DDMAs. governs the issues of calamities and emergencies. Before establishing the NDMA, disaster risk manage- The Punjab Civil Administration Act 2017 (Act III of ment was response-centric and governed by the Fed- 2017) for example, states that:18 eral Relief Commission 2005, Emergency Relief Cell 1971, and Calamity Act of 1958. After the NDMA was “The Government may, by notification, declare the established, there was a focal point to lead the work whole or any part of the Province, as the case may be, on preparedness and response in emergencies. The role as the calamity-affected area under Section 3 of the of NDMA, however, was limited to disaster risk man- Punjab National Calamities (Prevention and Relief) Act agement activities. NHEPRN was established to per- 1958 (XXXIII of 1958.)” form functions of health care preparedness, response, and recovery in disaster situations. The following mechanism is adopted in case of any calamity or emergency: NDMA and NHEPRN mainly deal with health and nonhealth emergencies using various plans • On issuance of the notification, the commissioner, and frameworks developed as per international deputy commissioner, assistant commissioner, or best practices. To deal with emergencies through- officers subordinate to them may, in consultation out the country, the NDMA Act 2010 put in place a with the respective head of the local government, well-established mechanism to cater to disaster man- exercise such powers within the area of their re- agement at the national, provincial, and district levels. spective jurisdiction as the relief commissioner However, the Act fell short of addressing health-relat- may delegate to them under Section 7 of the said ed emergencies. This was primarily due to the devo- Act. lution of health to the provinces and subsequent • All the offices in the district or, as the case may be, deletion of the health component from NDMA’s re- in the division shall extend such assistance to the sponsibilities. WHO’s IHR 2005, Hyogo Framework officer as he may require or as may be necessary for Action (HFA, 2005-2015), and Sendai Framework for the circumstances. for Disaster Risk Reduction (SFDRR, 2015-2030) • On a request by or on behalf of the deputy com- paved the way to integrate the disaster risk reduc- missioner, the local governments in the district tion framework with public health emergency set- shall also render such assistance to the deputy tings. Accordingly, in 2017, NDMA, in collaboration commissioner or officers subordinate to him as with NHEPRN, developed the NAP to implement may be necessary for the circumstances the Bangkok Principles on Health Aspects of the SFDRR. Different preparedness plans exist in every province. For example, the provincial disaster manage- The NAP was a blueprint for health interventions ment authority in all provinces has shown significant that would be aligned with the national disaster progress in the development of the Monsoon Con- response plan to reduce the threats posed by the tingency Plan in coordination with line departments effects of disasters and emergencies over the next and other stakeholders. Similarly, Punjab province 18 See details at http://punjablaws.gov.pk/laws/2677.html 47 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS has a Dengue Outbreak Emergency Plan of Action; 3.4 OVERVIEW OF THE Balochistan has a CCF plan, and KP has flood man- agement plans. All these different plans are present in MACROFISCAL CONTEXT the provincial context resulting in lack of one uniform budgeted emergency or nonemergency response plan It is important to understand the macrofiscal to cover every health security area that must be imple- context of Pakistan as it links the fiscal envelope mented on the whole provincial population. with the health spending of the country. A high level of nondiscretionary spending, low fiscal capacity, There exists a lack of provincial preparedness the composition of health expenditure, and the ratio and response to tackle emergencies and even of public health expenditure to total health expendi- nonemergency situations. Some bottlenecks exist in ture provide insights for policy making. Countries with the implementation of provincial IHR activities at the high economic growth are in a better position to en- policy level: hance health allocation and move toward UHC. This section explains the macrofiscal context of Pakistan • No province has developed a provincial health and its link with health spending. security action plan. • The majority of the emergencies are being Regionally, Pakistan lags behind the curve on tackled without any prior planning or strategic macrohealth indicators including current health guide. expenditure, and per capita health expenditure. • There is no PC-I in IHR areas for recruitment Pakistan’s GDP was third in the South Asian region and strategic directions. in 2018, but currently, the health expenditure (as a percent of GDP) is only 3.2 percent, lower than the average for the region which stands at 5.74 percent.19 It ranked higher only than Bhutan and Bangladesh which had a current health expenditure of 3.06 per- cent and 2.34 percent of GDP, respectively in 2018 (Figure 17F). Pakistan’s current health expenditure per capita (current US$) is also very low, that is, US$42.87 in 2018, far behind the regional average of US$ 216.61. In the same year, in Maldives the health expenditure per capita was US$973.54 (highest) and in Bangladesh was US$41.91 (lowest) across the region. Comparing Pakistan’s per capita health expenditure globally shows that the country needs to raise its expenditure as usual- ly, high-income countries spend US$3,000 on average on each citizen as compared to the low-income coun- tries (US$30) (Sfakianakis et al., 2020). A high level of nondiscretionary spending and debt has allowed Pakistan little fiscal space for health. Budgetary room is a critical factor that allows governments to allocate more money for health. A simple framework for assessing the budgetary room (fiscal space) for health is provided by Tandon and 19 South Asian Countries include Afghanistan, Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 48 RESULTS Cashin (2010) which can be explained as follows: nondiscretionary debt and defense payments. It is evident that after the mandatory payments the Gt+rtBt-1= Tt+Bt+At+Ot Government is left with less to spend on other sectors such as health. The left-hand side of the equation represents gov- ernment expenditure (Gt ) including the nondis- Pakistan is unable to translate economic develop- cretionary debt interest payments (rtBt-1). The ment into more money for health because of the right-hand side represents the sources of funding in- high fiscal deficit and low fiscal capacity. In the cluding tax ( Tt ), borrowing (Bt ), grants (At ), and other last 20 years, government expenditure has exceeded sources (Ot ). A high percentage of nondiscretionary the revenues and has constantly shown a fiscal deficit payments in total government expenditure means that ranging from 2.30 percent of GDP in 2004 to 9.10 per- government can spend less money through a budget cent of GDP in 2019. Because of the fiscal deficit, the appropriation to high priority areas including health. federal and provincial government health expenditure In Pakistan, the share of nondiscretionary expenditure remained less than 1 percent of GDP from 2000 to (interest and defense) to total government expenditure 2016—the lowest 0.57 percent of GDP in 2002 and is very high, that is, 38 percent on average in the last 20 the highest 0.9 percent of GDP in 2016. Similarly, a years. The Tandon equation can be written for Pakistan study by McIntyre et al. (2016) shows that if the gov- as follows: ernment spending to GDP ratio is between 20 percent to 25 percent it has low to medium fiscal capacity. Gt+rtBt-1+kt Dt-1=Tt+Bt+Et+Pt Pakistan’s average spending to GDP ratio in the past 20 years has been around 19.8 percent which shows where (Gt ) is the government Non-Interest, low fiscal capacity. Pakistan’s GDP growth is shown in Non-Defense Expenditure, and (rtBt-1), (ktDt-1), are Figure 15.20 Figure 15: Pakistan’s GDP Growth (%) 20 Real Growth Rates of GDP at constant basic prices of 2015-16. Source Pakistan Bureau of Statistics 49 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Gross debt as a percentage of GDP and govern- cent of GDP in OECD countries. Pakistan is making ment deficit as a percentage of GDP are areas of efforts to improve the tax to GDP ratio and initiated concern when assessing the GoP’s longer-term a US$400 million project in 2019 with the help of the capacity to spend. Low-income countries with a high World Bank to strengthen the Federal Board of Rev- burden of debt are at odds to increase government enue (FBR) capacity to generate sustainable domestic health spending. If gross debt as a percentage of GDP revenue through tax reforms. This reform will further is under control and the fiscal deficit is in check Gov- increase the tax to GDP ratio in the coming years (The- ernment can increase the financial resources for health World Bank, 2019). through deficit financing. IMF has recommended that the ‘acceptable’ debt to GDP ratio should be around The question of how effectively the Government 60 percent for high-income countries and 40 percent translates economic growth into revenue has a ma- for low- and middle-income countries. Pakistan has jor implication for the health sector. More revenue witnessed a soaring ratio of national government debt as a result of economic growth allows governments to to GDP in the last 20 years (Figure 17E). On average it allocate funds to priority areas like health. In the last 20 remained 69.17 percent of GDP with the highest 56.4 years (2000-2020) on average, a PKR 1 billion change percent of GDP in 2007 and a maximum of 87.9 percent in the GDP has resulted in a PKR 0.13 billion positive of GDP in 2001. At the same time, Pakistan’s annual increase in revenue which is a good sign. However, the percentage growth rate of GDP (real) was 4.40 percent Government of Pakistan should work on translating (average) in the last 20 years. In the coming years, Paki- more revenues into more money for health. For ex- stan has to curtail the high debt as the interest payments ample, Pakistan’s ratio of converting the Government’s on debts have lowered the capacity of the Government revenue into current health expenditure is very low (21 to increase spending in general and health spending percent) in the region (Figure 17F). Afghanistan has in particular. The Government’s ability to borrow to the highest ratio of 72 percent followed by Maldives finance health is also hampered by the fact that the fis- (53 percent), India (27 percent), Nepal (26 percent), cal deficit as a percentage of GDP is also growing con- Bangladesh (23 percent), and Bhutan (17 percent). stantly. In short, Pakistan’s chronic fiscal deficit along- side the high debt to GDP ratio has limited its ability to allocate more money to health. Figure 16: Per Capita Health Expenditure (US$) GoP is unable to create fiscal space for health based on economic growth only. Globally, economic development is highly correlated with health spending in general, and government health spending in partic- ular (Barroy et al., 2018). A simple regression analysis on the last 20 years (2000-2020) of data shows that a 1 percent change in GDP has translated into a 0.01 percent increase in federal and provincial government’s health expenditure and only 0.0007 percent change in health expenditure per capita. The Government has to think of alternative ways to bring more investment to the health sector. Pakistan’s tax to GDP ratio is very low despite The composition of health expenditure is highly tax being the major source of revenue for health. inequitable in Pakistan. Research has shown that Pakistan’s major source of revenues is tax revenues the major source of sustainable health financing came which constitute 70 percent of total revenues (Figure from government sources (Islam et al., 2018). If the 17D). However, the tax to GDP ratio is very low, that major portion of health expenditure is financed by the is, 13 percent of GDP in 2018 as compared to 34 per- Government, it can allocate more money to priority PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 50 RESULTS interventions. Similarly, high dependence on out-of- (7 percent) (see Figure 17B). pocket (OOP) expenditure can slow the progress to- ward achieving UHC. In the last 20 years (2000-2020), There is significant variation in the provincial Pakistan’s current health expenditure (CHE) as a per- health expenditure in response to NFC transfers. centage of GDP has been around 2.8 percent. It has It is estimated that between 2013 and 2018 1 percent four components—federal and provincial govern- change in NFC transfers on average led to a 10 per- ment’s health expenditure, domestic private health cent change in provincial health expenditure in Punjab, expenditure, OOP, and external health expenditure 4 percent change in Sindh, 2 percent change in KP, and (Figure 17A). In the last 20 years on average, 65 1 percent change in Balochistan. percent of health expenditure is financed from OOP, 24 percent by the Government, 3 percent by external The current health expenditure of the coun- sources, and 8 percent by domestic private sources.21 In try is inadequate to exert pressure to influence 2018 Pakistan’s OOP expenditure was 56.24 percent of priority health interventions. The current health current health expenditure. spending is increasing very slowly and remained less than 1 percent of GDP for almost 17 years (2000- High dependence on OOP is the major barrier 2016) going beyond 1 percent after 2017 (Figure 17C). to the pooling and purchasing arrangements for With this trajectory, it will be around 1.42 percent of health in the country. The government share in total GDP by 2026. At the same time, Pakistan has made health spending has increased in the last 20 years but the meaningful progress toward UHC by commiting to dependence on OOP is still very high. Heavy reli- various health initiatives. Two prominent health com- ance on OOP is not only inequitable but has a serious mitments are approving the NAPHS and the devel- consequence, resulting in financial hardships for the opment of Pakistan’s first-ever national UHC benefit public leading to catastrophic health expenditure. package. These two commitments are timely but will put pressure on the Government to increase health Development assistance to health has grown at the spending quite rapidly. Implementing NAPHS will re- rate of 11.85 percent on average in the last 20 years. quire PKR 111.27 billion over the next five years. Sim- It is considered an alternative source of health financ- ilarly, there is a financing gap of PKR 841.23 billion to ing but the reliability and flexibility of such assistance implement the UHC benefit package in the next five is always an issue in the long term. The Government years. Pursuing such intervention means that the cur- must raise the share of government expenditure in to- rent health spending should reach 2.0 percent of GDP tal health expenditure for sustainable financing. by 2026. With the current fiscal deficit and constrained fiscal space for health, this would be quite a challenge Health spending at the provincial level also varies for the Government. as a consequence of devolution. After the devolu- tion necessary resources are distributed to the prov- Health expenditure in comparison with education, inces through NFC awards. Currently, the 7th NFC social protection, interest payments, and military is in progress; from 2013 to 2018 PKR 11,483 billion spending is insufficient at the federal level. Table 6 has been transferred to the provinces (WHO Mission below shows that at the federal level the current bud- Report, 2019). The total public sector health expen- get is very small to fund the health expenditure and diture between 2013 and 2018 was PKR 1,352 billion it is mainly financed by the development budget. At in which the federal share was only 15 percent and the provincial level, the level of health spending varies 85 percent was spent by the provinces. Punjab spent as per the provincial government priorities. Punjab, for the highest at PKR 538 billion (40 percent) followed example, spends more the 20 percent (current and de- by Sindh PKR 353 billion (26 percent), KP PKR 165 velopment combined) of its total budget on health. KP billion (12 percent), and Balochistan PKR 95 billion and Sindh spend a major portion on health through 21 The share of current health expenditures is funded from domestic private sources. Domestic private sources include funds from households, corporations, and nonprofit organizations. Such expenditures can be either prepaid to voluntary health insurance or paid directly to health care providers. 51 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS the current budget, whereas Balochistan health expen- diture is equally financed through the development and recurrent budget. Table 6: Health Expenditure in Comparison with Other Sectors (%) Current Revenue Expenditure Develpoment Revenue Expenditure 2017-18 2018-19 2019-20 2017-18 2018-19 2019-20 Federal ( Total Expenditure): 100.00 100.00 100.00 100.00 100.00 100.00 Health 0.34 0.29 0.15 10.07 7.03 3.13 Education 2.40 2.04 1.06 8.28 10.02 8.35 Social Protection 0.06 0.05 2.62 0.11 0.27 0.19 Interest Payments (Debt Servicing) 43.83 46.48 54.70 0.00 0.00 0.00 Military Spending (Defence) 24.45 23.02 15.81 0.93 0.68 0.44 Others 28.92 28.12 25.66 80.61 82.00 87.89 Punjab (Total Expenditure) 100.00 100.00 100.00 100.00 100.00 100.00 Health 10.88 10.91 11.18 9.27 15.97 14.60 Education 4.34 5.61 5.49 13.51 16.91 14.75 Social Protection 0.68 0.63 0.75 0.28 0.26 0.50 Others 84.10 82.86 82.58 76.94 66.86 70.14 Sindh (Total Expenditure) 100.00 100.00 100.00 100.00 100.00 100.00 Health 12.80 12.87 13.42 4.48 3.54 5.35 Education 26.81 26.51 24.81 6.14 6.96 8.99 Social Protection 1.42 1.23 1.13 30.58 26.63 29.36 Others 58.97 59.39 60.65 58.79 62.87 56.29 KP (Total Expenditure) 100.00 100.00 100.00 100.00 100.00 100.00 Health 6.93 8.26 8.52 7.47 5.94 4.00 Education 7.10 7.89 7.33 12.73 12.87 9.55 Social Protection 1.55 1.87 5.04 4.73 2.95 3.26 Others 84.45 81.98 79.10 75.07 78.24 83.19 Balochistan (Total Expenditure) 100.00 100.00 100.00 100.00 100.00 100.00 Health 7.55 7.35 7.62 6.99 8.50 6.31 Education 18.88 21.41 21.27 11.11 14.43 10.17 Social Protection 1.63 1.50 1.46 1.85 1.95 12.49 Others 71.94 69.73 69.65 80.05 75.12 71.03 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 52 RESULTS Figure 17: Pakistan— Macrofiscal Indicators 53 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Govt. revenues as % of GDP PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 54 RESULTS Some of the important areas where GoP can low priority areas in other sectors to health. There is improve the fiscal space for health are mobilizing also room to reallocate within the health sector, by us- additional tax revenues for health, reprioritizing ing cost-effectiveness analyses to help policy makers re- the budget for health, and improving spending allocate funding from cost-ineffective health interven- efficiency. tions to cost-effective health interventions. To achieve this, there is a dire need for the health sector to acquire Fiscal space for health can be increased by training and technical skills in allocative efficiency and earmarking taxes for health. To achieve this cost-effectiveness analyses, as well as high-level politi- objective there is a need to develop a concrete plan cal commitments to apply them into policy. to further increase excise taxes, and allocate increased revenues to the health sector. In 2018 MoNHSR&C It is necessary for health ministries to undergo imposed excise taxes on tobacco and sugar-sweetened an efficiency assessment that leads into a rap- beverages (SSBs) (federal health levy). However, in the id, evidence-based, multistakeholder process to 2020-2021 budget, no additional taxes have been laid diagnose technical inefficiencies throughout the on tobacco and SSBs to raise revenues for health. health system. Efficiency in health spending is a ne- glected area and has been shown to improve health Reprioritizing the budget is one way to increase spending considerably (Pan American Health Orga- spending. One of the key reprioritization practic- nization, 2020). In an interview with senior finance es in lower- and middle-income countries is to intro- officials at the MoNHSR&C, it was ascertained that on duce cost-saving interventions in national strategic average the health ministry surrenders 40 percent of its health plans. With a restricted budget and competing allocated budget that is unspent every year to the Trea- priorities, the Government of Pakistan could use the sury. So far no assessment has been done either at the allocative efficiency analysis among various sectors to federal or provincial levels to assess spending efficiency determine the possibility of reallocating funding from in the health sector. * MTBF - The Medium-Term Budgetary Framework 55 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS 3.5 FINANCING FOR HEALTH The structure of the health budget determines the level of health spending on priority areas like SECURITY BUDGETING AND IHR. The health budget in Pakistan is composed of RESOURCE ALLOCATION the current and development budget.22 The current budget usually is nondiscretionary and used to run A firm understanding of the process of budget the day-to-day affairs of the federation that includes approval, budget structure, PFM rules, and the role salaries and administrative expenses, debt servicing, of MoNHSR&C in budget formulation builds a loan repayment, etc. The MoNHSR&C along with strong case for health allocation and health securi- the provincial departments has very little control over ty. This section gives an overview of the “generalized” this budget and cannot reappropriate it easily. A part and “health security-specific” financing mechanisms of the current budget is used to fund IHR core activ- and all the processes and appropriations of funds for ities like salaries of government staff working on JEE health security. The section further highlights the areas technical areas, workshops, training, and other that need improvement and recommends policy action administrative expenses. for the MoNHSR&C to increase health allocation. The development budget is meant to meet the The Prime Minister approves the schedule of developmental initiatives of the Government. authorized expenditure, and only such expenditure The development budget is prepared from alloca- can be incurred, which is approved. The Federal tions made for development expenditures, also known Budget of Pakistan, also known as the general budget, as the Public Sector Development Program (PSDP). is prepared and presented to the National Assembly Usually, the development budget is a discretionary by the Federal Government. According to the Consti- budget and most of the priority health interventions are tution of Pakistan, the budget has to be submitted for initiated through it by approval of PC-I. In the context legislature approval as a “money bill” that originates of IHR, three PC-Is have been approved to date from only in the National Assembly. The approved budget the development budget, including PoE, Antimicrobi- encompasses the estimates of receipts and expenditure al Resistance, and Integrated Disease Surveillance and for one financial year from July 1 to June 30 with cor- Response (IDSR). The IDSR PC-I also includes the responding figures of the previous year. The constitu- Field Epidemiology & Laboratory Training Program tion of Pakistan mandates that all government receipts (FELTP) and Public Health Labs (PHL). The current and expenditures should be made through a Federal and the development budgets together form the total Consolidated Fund (FCF) account (Article 81), which health budget at the federal and provincial levels. is maintained by the State Bank of Pakistan (SBP) under the State Bank Act. The FCF and Public The PFM rules of the country govern the process- Account of the Federation (PAF) are the two main es of the budget cycle in the country. Box 1 lists the accounts that receive money raised by or on behalf of steps of the budget call circular in Pakistan that starts the Federal Government (Ministry-of-Finance, 2020). from setting the budget strategy and ends at budget review.23 During the budgetary process, the finance de- The health budget is part of the federal budget partment of the MoNHSR&C liaises with MoF on that supports financial commitments to imple- the budget ceiling for health, expenditure control, and ment health policies and strategies. The federal and tracking expenditure as per line-item budget alloca- provincial budgets show the overall financial commit- tions. This close collaboration between the MoNHS- ments of the Government. The health budget provides R&C and MoF ensures that spending is in line with the aggregated information on revenues and expenditures, health objectives and moving toward implementing the earmarked for a fiscal year and revised estimates for the health sector reforms outlined in the National Health outgoing fiscal year. Vision 2016–2025. 22 Development budget means expenditure provided in grants, relating to development projects. Development projects undertaken to acquire, build or improve physical assets or develop human resources. Whereas A recurrent budget consists of regular revenues and ongoing expenses. 23 In Pakistan the budget cycle consists of six steps and includes: setting of budget strategy, preparation, authorization, implementation, reporting and monitoring, and budget review. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 56 RESULTS The Medium Term Budgetary Framework appropriating budget to priority health interven- (MTBF) is a PFM tool that has been used across tions including IHR. Line-item costing allocates and government to link policy priorities to health tracks expenditure by the type of expenses or cost cate- expenditure allocations within the fiscal evelope. gories available in the financial system of the country. To The MTBF was introduced in Pakistan in 2003 with allocate and track health-spending, MoNHSR&C donor support (Oxford Policy Management, 2014); works with the Controller General of Accounts (CGA). since then all ministries are required to specify how The CGA is responsible for the smooth functioning the inputs (resource provided) are used to provide the of the SAP-based Financial Accounting & Budgeting outcome (a delivered service or product). Ideally, the System (FABS), which is an Integrated Financial Man- MTBF should be linked with the revenue forecasts agement Information System (IFMIS) being run at provided by the MoF and with the expenditure forecast government offices at the federal, provincial, and dis- provided by the MoNHSR&C to improve the quality trict levels. The current IFMIS generates general pur- and credibility of the annual budget. However, to date, pose financial reports through the system of Charts the MTBF has not covered the health sector in Paki- of Accounts (CoA)—a critical element of the IFMIS stan. Recently, the Government provided the Perfor- for classifying, recording, and reporting information mance-Based Budget 2021-2022 to 2023-2024 to com- on financial plans, transactions, and events.24 These ply with the MTBF requirements. However, there is a charts of accounts cover transactions related to expen- complete separation between the MoF precedence and diture and revenues. The Accountant General Pakistan the health ministry priorities. The key activities planned (AGP) demands that all the expenditures and receipts in the NAPHS to implement IHR are not part of the must be classified as per CoA rules. This CoA frame current three years MTBF reforms (Finance Division, work is based on the Entity Element, Fund Element, 2020). Function Element, Object Element, Project Element, and Location Element. A brief description of each is Line-item budgeting is a major deterrent in given in Box 2. Box 1. The budgetary allocation/ estimation in Paki- Planning Commission and copied to FAs/DFAs. stan is an annual exercise initiated by the Additional 8. Submission of Forms for Budget Computeriza- Finance Secretary (budget) who issues a budget call cir- tion (Budget Wing, Finance Division). cular for the ongoing financial year to all Secretaries/ 9. Review and approval of budget estimates and Additional Secretaries in charge of ministries/divi- additional demands (current plus development) by sions. Key steps in the budget circular are listed below. the Priorities Committee. 1. Issuance of ‘Budget Call Circular’ to the Principal 10. Completion of budget review and approval Accounting Officers (PAOs). process—APCC meeting. 2. Preparation of the Budget Strategy Paper and its 11. Completion of budget review and approval presentation in the Cabinet. process— NEC meeting. 3. Issuance of Indicative Budget Ceilings for current 12. Finalization and submission of the and development budgets to all PAOs. final Medium-Term Budget Estimates for 4. Preparation of the medium-term Strategic Plan. Service Delivery’ (to the Finance Division. 5. Filling of the Budget Forms. 13. Completion of all Budget Documents (including 6. Submission of forms for the current budget by the ‘Green Book’), Schedules and Summaries for ministries / divisions to FAs / DFAs for quality Cabinet approval. assurance. 14. Presentation of the Budget (including the ‘Green 7. Submission of forms for the development budget Book’) to the Cabinet and Parliament by ministries / divisions to Sector Chiefs in the 24 The AGPR uses the New Accounting Model (NAM), a system of classifying expenditure under new Chart of Accounts (CoA). NAM was prescribed by the Auditor General of Pakistan under the Project to Improve Financial Reporting and Auditing (PIFRA). 57 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS In the current government’s system of bud- slow progress in implementing IHR. Mid-term geting, expenditures and revenues cannot be budget planning is the first step in the budget cycle identified for the JEE technical areas. If the where the MoNHSR&C should work closely with the particular ministry, department, or division is working MoF. MTBF requires output-based budgeting (also on a JEE area, the allocation and expenditure can only known as performance-based budgeting) whereas, be traced as per the classification shown in Box 2. To currently all the budget allocation and spending in the trace how much is being spent or allocated for spe- country follows input-based budgeting (budgets are al- cific JEE areas, a detailed mapping exercise must be located by department, fund, and expense type, etc.). performed each year. One exception to this challenge Although an Excel-based template has been shared is vertical programs, where the JEE-specific CoA has with MoNHSR&C to specify the output and outcomes been configured in the government financial system. expected to be achieved against the funds appropriat- Currently, eight vertical programs are running across ed, these are not well understood by the ministry staff the country (Planning Commission, 2020). Out of who are only trained on the functional and object clas- these eight programs, EPI directly addresses one JEE sifications of the CoA in the budget. According to an area, that is, immunization. Hence, all the expenditure official of the Department of Finance, MoNHSR&C: for immunization programs is easily identifiable from the government budget. However, it is challenging for “We don’t use the performance-based budgeting as a other JEE technical areas to trace the budget or expen- tool for budget planning. We get the allocation as per diture from the government financial system. the functional and object classifications, and also spend accordingly.” The role of the MoNHSR&C in health budget cycle formulation and execution is weak and As a result, the recent MTBF 2021 does not include should be improved. The health security financing as- major strategic allocations for health including IHR. sessment shows many areas where the federal ministry This exclusion of MTBF, in the long term, can lead to should build its capacities (Figure 18). Some of the key no or insignificant spending on core IHR areas from areas are: the development of health-specific MTBF, the government budget. To adopt MTBF for trans- re-prioritizing budget, and efficiency savings. parent fund allocation, the MoNHSR&C should take a stewardship role and actively participate in the devel- The absence of health-specific MTBF has led to opment and execution of health specific MTBF. Box 2: Code Classification for Reporting of Transaction Budgeting Entity Element Financial reporting by: government, ministry, division, attached department, district, and Drawing and Disbursing Officer (DDC) Fund Element Financial reporting by: consolidated fund or the public account fund Function Element Financial reporting by ten heads: 01 General Public Service; 02 Defense Affairs & Services; 03 Public Order and Safety Affairs; 04 Economic Affairs; 05 Environment Protection; 06 Housing and Community Amenities; 07 Health Affairs; 08 Recreation, Culture and Religions; 09 Education Affairs and Services; 10 Social Protection Objective Financial reporting by thirteen heads: A01 Employee Related Expense; A02 Project Preinvestment Element Analysis; A03 Operating Expenses; A04 Employee Retirement Benefits; A05 Grants, Subsidies and Write-off of Loans/Advances/Others; A06 Transfers; A07 Interest Payments; A08 Loans and Advances; A09 Expenditure on Acquiring of Physical Assets; A10 Principal Repayments of Loans; A11 Investments; A12 Civil Works; and A13 Repairs and Maintenance Project Element Financial reporting by: core projects developments, sectoral projects development, and nondevelopment Location Element Financial Reporting by: district, tehsil, and union council Source: Budget Manual, first edition, January 2020, Finance Division, GoP. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 58 RESULTS The scope of budget reprioritization is limited Improving technical efficiency can substantially and should be broadened. During budget planning, improve the health spending on JEE technical the MoNHSR&C should work with MoF on budget areas without raising new revenues for health. reprioritization for IHR. The staff at the federal minis- According to a respondent from the Department of try, however, are not part of the budget reprioritization Finance, MoNHSR&C: exercise and have little role to play. According to an official of the Department of Finance, MoNHSR&C: “The easiest way to increase “To actively participate in budget health spending on IHR activities planning, I think ministry should is to build our capacity to spend build our capacity. Usually, we the allocated money through the are not part of budget reprioriti- budgetary process. Most of the zations and have never worked on time we spend only 60 percent of fiscal space for health. If we want the budget. If we can spend 100 to allocate more money to IHR re- percent of the budget, the spending lated activities, the training of the will automatically be improved by staff responsible for dealing with 40 percent.” the budget must be done.” In light of the observations above, the following key actions are recommended. The CoA should be In the current budget, the Government has taken configured with the help of relevant stakeholders various steps to reprioritize the health sector. However, including MoNHSR&C, AG office, Finance Division, the scope of work is limited to RMNCH and other and others so as to be able to track the most important infrastructural reforms like increasing the number IHR function related expenditures. This will help to of Basic Health Units (BHUs), and Rural Health track and allocate health expenditure as per the JEE Clinics (RHCs) (Finance-Division, 2021). Higher-level technical areas in the coming years. It will also reduce advocacy should be adopted by the MoNHSR&C to the rigid input-based budget allocations and allow for broaden the scope of the reprioritizing exercise for the more flexible output-based budgeting. Moreover, the health budget in light of the recent outbreak of the capacity of the MoNHSR&C should be built to develop COVID-19. health-specific MTBF, the MoNHSR&C should work closely with MoF on budget reprioritization, and finally conduct an efficiency assessment. 59 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Figure 18: Role of the MoNHSR&C in the Budget Cycle PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 60 RESULTS 3.6 RESOURCE MOBILIZATION —REVIEW OF HEALTH FINANCING IN PAKISTAN To assess progress towards UHC in general and (ESSI)—the institute that collects the money from Universal Health Security (UHS) in particular, an the individual and then works as a purchasing agent understanding of health financing arrangements to purchase health care services; 0.7 percent of pooled of the country is essential. This section gave an funds come from this source. A very small portion, overview of the sources of finances for health, how 1 percent of pooled funds, comes from Zakat and Bait money is raised, what are pooling mechanisms, and ul-Mal funds. who uses the money to purchase and provide health care services. The data for health financing is taken Purchasing is an important area of health from recent National Health Accounts 2017-2018 and financing and ensures equitable and efficient shows the revenue-raising, pooling, and purchasing use of resources. In Pakistan, the major portion of arrangements in the country. Figures 19 and 20 provide purchasing is from private households (52 percent), the pictorial view of these arrangements. and the government (39 percent). Other purchasing agents include autonomous bodies, health insurance Various sources are used to finance health at the companies, social security companies, and local NGOs. federal and provincial levels in Pakistan. The major source of revenue is private OOP, which constitutes The provision of health services is shared between more than 50 percent of total revenue raised for public and private bodies. Health care services are health. The second source is government expenditure provided mainly by hospitals -both public and private-at and 40 percent of the revenue comes from it. These the federal and provincial levels. These hospitals work two sources add up to 90 percent of revenues raised at primary, secondary, and tertiary levels and contribute for health. The remaining (10 percent) revenue is 40 percent of the total health service delivery in the raised through donors, local NGOs, and employer country. Retail sales and other providers of medical funds. To provide sustainable financing and equity in goods also provide medical services in the country raising revenue the share of OOP must be reduced and through dispensing chemists, suppliers of optical replaced by government sources. glasses, hearing aids, miscellaneous sales, and other suppliers of pharmaceuticals and medical goods. Their Several sources are used in Pakistan to pool funds share in the provision of health services is 26 percent. for health. The biggest source is OOP payments; 88 Providers of ambulatory health services constitute 19 percent of pooling comes from this single source. percent and have 10 subcategories including health The second source is local NGOs that contribute 9 practitioners, physicians, outpatient care centers, etc. percent toward the total health pool and use funds Moreover, the share of the Sehat Sahulat Program, from the Bait-ul-Mal as well as from other sources.25 local NGOs, and private insurance companies that The third source is private health insurance companies provide health services is 19 percent in health service that contribute 2 percent of the total pooled funds of delivery. The other health service providers are general the country. In this pooling arrangement, a premium health administration and insurance and the rest of the is collected from the individuals, and in return, the world (direct funding by donors to government). recipient can avail of health services through hospitals, dispensaries, and other health care providers. The The fund flow mechanisms from revenue raising fourth source is Employee Social Security Institution to service providers are inadequate. Taxes are 25 A form of social assistance with mandatory Zakat deduction at the rate of 2.5 percent from different savings accounts. 61 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS the main sources through which government raises The following conclusions can be drawn from a review funding; however, no pooling mechanism exists for of Figures 19 and 20. taxes, and the funds are used by the Government to purchase health services through public and private The share of OOP payments is very high and as entities. The process of earmarking taxes (either hard a consequence provides less financial protection or soft) for health is yet to be implemented and is to individuals. An important area linked with expected to substantially improve government capacity financial protection is the share of catastrophic health to increase health spending. This can be achieved if the expenditures from OOPs. Currently, NHA does not tax to GDP ratio is increased and additional revenue is provide information about the share of catastrophic given to the health sector. Individual contributions are expenditure in health spending the second source of revenue-raising pooled by various mechanisms including, public and private Zakat, social Pooling arrangements are inadequate for the security schemes, Bait-ul-Mal fund, and an employer public sector. Three main pooling arrangements from fund. The funds raised are used by registered NGOs, the government side are Zakat, Bait-ul-Mal, and ESSI. social security organizations, and the government to However, they constitute a very small pool and are not purchase health services. This mechanism is highly adequate to provide financial protection to the public inequitable as the main burden is on the individuals and at large the purchasing of health services is not efficient. The There are currently no assessment results available employer contribution is the third source of revenue- to check how the funds received by the Government raising for health. The secured employees incur no are utilized efficiently to purchase health services. deduction, copayment, or any other cost to avail of One area that can improve the progress toward UHC these services. The funds pooled are directed to ESSI is to check the utilization of available resources when then procures the health services from hospitals, purchasing services. ambulatory health services, or others. The contribution, however, of ESSI and employer contribution in revenue-raising, pooling, and purchasing is very basic and can be strengthened further. PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 62 RESULTS Figure 19: A Functional Summary Chart for Pakistan (2017-2018) 63 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Figure 20: Fund Flow Mechanisms from Revenue Raising to Service Providers PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 64 RESULTS 3.7 CONSTRAINTS AND LIMITATIONS The staff at the federal and provincial levels argued that one of the reasons for not getting budget alloca- OF THE CURRENT PLANNING AND tion by JEE technical areas is input-based budgeting. BUDGETING PROCESSES The major drawback of input-based budgeting is that the funds are not allocated to the priority health inter- This section highlights issues in the current planning ventions like IHR which require funds against 19 JEE and budgeting processes for IHR in Pakistan. The list technical areas. According to an official of the Depart- of issues has been compiled after in-depth interviews ment of Finance, Punjab: with the finance staff at different ministries at the fed- eral and provincial levels. The findings are generally ap- plicable to the health sector but during the interview, “We did not receive budget as per the emphasis was on IHR-related financing and bud- geting processes, therefore the issues address major the JEE technical areas, rather barriers to raising financing for IHR. it is strictly based on inputs like Budget allocation is not aligned with health sector priorities. The interviewees at the federal ministries salary, op erational expenditure, and provincial departments believed that the budget etc. The spending on IHR-related allocation was not aligned with health sector priorities like IHR. The current budgeting is a standardized pro- activities could improve substan- cess where a request is generated from the department of health to the finance department requesting funds. tially if we receive budget by JEE The funds are allocated to the spending entity accord- ing to approved budget heads and not by JEE prior- thematic areas like AMR, PoE, ities. According to an Official of the Department of etc.” Finance, MoNHSR&C: “Health policies developed at the The budget release process causes various prob- MoNHSR&C are not part of lems for the spending entity. Cash management has the budgeting process. You won’t been used as a tool to assist performance-based bud- geting. The objective of cash management through a find any specific budget line for system of release management was to ensure effective budget implementation. However, with time the sys- JEE technical areas like zoonotic, tems of the cash release have become an obstacle rath- er than a tool. After the legislature approves the money AMR, or surveillance. Even the bill, budget execution is subject to budgetary release NAPHS was never translated by multiple departments/functionaries of the GoP. Numerous checks are built into the release process, into the budgetary allocations for and the same is applied at the payment stage instead of at the commitment stage. Resultantly, the release IHR. That is why the spending process is subject to multiple controls and numerous checks, which make budget execution cumbersome. on IHR-related activities is very According to an official of the Department of Finance, low.” MoNHSR&C: 65 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS exist huge liabilities of arrears that remain unpaid be- cause no funds were foreseen for their payment by the “Getting the cash release from the Planning Commission and MoF for multiple reasons, including the need for revision in PCI, approval of the finance division is an uphill task; supplementary grant allocation in PSDP, and other such we usually get less money than we issues. asked but the situation is even In Pakistan, fiscal decentralization as a result of devolution has not worked as expected. The 18th worse for the development budget Amendment to the Constitution delegated most of the public service delivery functions to the provincial releases.” governments. As a consequence, PFM became a hy- brid system of rules, regulations, and procedures for the federal as well as provincial governments. This sys- tem involves multiple layers of checks and numerous The complex budget release process on occasion officials in budget execution, implementation, release creates a problem for the procurement department. processes, etc. The staff working at the federal min- In many cases, payments for procurement cannot be istry and provincial health departments believed that done in a piecemeal fashion. For instance, where the devolution had not been a success. Specifically, fiscal whole equipment is required to be purchased in one go, decentralization is still not complete. According to an then the invoice has to be processed for the whole of officer in the Punjab province: the equipment. In such cases, the procuring agencies are not authorized to spend the whole of the budget of the physical asset in the first quarter. If they opt to wait two or three quarters, it will attract objections “Decentralization was supposed to to the non-release of funds due to nonutilization by the Ministry of Planning, Development, and Reforms increase the provincial autonomy, (MoPDR) or MoF. Due to this cumbersome release but we are still dependent on the process, some of the procuring agencies prefer not to go for procurement by the time the release is available. federal approval to spend. As such They believe that if procurement is made without the release of the budget, they will not be able to honor the fund flows between the federal the supplier’s invoice, resulting in litigation and com- plaints against them by the suppliers/contractors. On and provincial level are still at the the other hand, the procurement cycle under the Public predevolution stage.” Procurement Regulatory Authority (PPRA) rules takes three to four months on average. This eventually makes specialized procurement next to impossible, which ul- timately adversely affects the service delivery capabil- ity of government functionaries.The budget release Fund flow from the federal government to the provin- process can be improved if the ministry and depart- cial government is governed by the consolidated fund ments build their capacities to develop cash flow plans. maintained by the Central Bank, and State Bank of Currently, the capacity of ministries and line depart- Pakistan. All the expenditure of the provincial gov- ments is limited to estimating the cash requirements ernments is meted through the consolidated fund. which leads to underbudgeting. This is mainly because Each province has an Accountant General, who is the accounting and recording of commitments and the custodian/signatory of the consolidated fund and stock of arrears are absent from the government fi- maintains the checkbook of the said account with the nancial management system. Whereas, in reality, there SBP. The health departments of the provincial govern- PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 66 RESULTS ment route all their payments through the Accountant Devolution has given autonomy to the provincial General’s office. However, the Accountant General government to oversee the IHR implementation but (AG) offices are governed by the federal legislation of the coordination between the federal and provincial the Controller General Accounts Act, 2001, and this governments is not clearly defined. NAPHS was devel- function continues to remain with the federal govern- oped in close collaboration with the federal ministries ment even after devolution. The AG offices are em- and provincial departments; however, the coordination powered to conduct a pre-audit check and thus can required to implement the NAPHS is still missing. No refuse payment of an expenditure incurred by a pro- periodic supervision is in place either at the federal vincial government functionary for any reason. This or provincial level to see how much budget has been multilayer approval process makes the release process allocated to JEE technical areas, what is the cumbersome and time-consuming. provincial spending against JEE technical areas, how many activities have been funded as mentioned in NAPHS, Federal approval is still required for procurement even and what are the funding gaps. after provincial autonomy. Almost all the provinc- es highlight the issue that even though the provinc- Fragmented input budgets create uncertainty in es are responsible for their respective procurements resource allocation. Currently, the recurrent and de- they have to seek federal approval. An official of velopment side of the budget is used to finance health Balochistan opined: security activities. The current side of the budget is mainly being utilized to run the normal affairs of the ministry and the development side to finance the JEE technical areas. The major challenge of the develop- “To initiate the procurement, the ment budget is that it is not allocated to federal and provincial entities based on some agreed principles. health departments of provincial As a result, the health departments are unable to plan governments, have to first seek the budgeting process accordingly. An official of the Department of Finance, MoNHSR&C commented: the budget and its release from the provincial finance department. “We usually know the budget Then comply with the respective allocation from the recurrent side provincial rules for procurements, for the coming year, as the alloca- and then comply with complex tion is based on the previous year’s federally issued instructions and performance. But in the case of orders during pre-audit checks the development budget, there is no applied by the AG office at the formula for next year’s allocation. time of payment for any goods or If we know how much money will services. All these procedures are be available through the develop- very complex and lengthy.” ment side of the budget, we can plan better.” 67 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 RESULTS Foreign aid for health security is fragmented. Data There is no mechanism to redirect funds if donors fail reveals that there has always been a difference between to meet their commitment. Moreover, in comparison the commitments and disbursements of donor aid in to sectoral distribution, the geographical distribution IHR-related activities. For example, the public health of donor aid in the health security area has been fluc- lab system is one of the JEE technical areas that need tuating over the years. In absolute terms, the province serious attention in the context of its basic infrastruc- of Punjab has always received more attention from ture, equipment, human resource, and diagnostic ma- donors compared to Sindh and KP, while Balochistan terials for it to function properly. There is a delayed seems to be the most neglected province. There is a donor’s commitment to lab establishment and logistics lack of support from the federal and provincial gov- support and long-term sustainability in provinces. An ernments to provide funding to provinces where fund- officer at a federal ministry opined: ing is relatively low in comparison to those where am- ple foreign aid is coming in. “One of the disadvantages of for- eign funding is that it is not part of the health budget. Most of the time the money is spent without taking us into the loop.” Another officer from KP opined: “The problem with the off-budget support is that it is often allocated to programs or projects. These pro- grams and projects are not equita- ble, that is, they are not designed to serve the country’s priority pop- ulation. In this sense, this donor funding creates fragmentation as well as creates inequity in provid- ing health services.” PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 68 FINDINGS AND RECOMMENDATIONS 0 . Findings and Recommendations 69 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 FINDINGS AND RECOMMENDATIONS This section highlights the main findings of the HSFA. federal level. Given the multisectoral nature of health The findings are organized as per the HSFA tool that security, health security spending not only represents builds its narrative around various pillars namely, health the health sector but also spending from relevant security activities in the country, the financing for government agencies in charge of health, agriculture, health security, funding for specific health security ar- environment, industries, commerce, etc., at the federal eas, macrofiscal context for health security, and finally and provincial levels. the constraints and limitations of current planning and budgeting processes. There is a disparity in funding for JEE technical areas at the federal and provincial levels. At the federal level immunization is the only area that gets 4.1 FINDINGS most of the funding and almost 95 percent of feder- al-level health security funding is allocated to it. Areas Pakistan has kept pace with IHR activities and the like real-time surveillance, national laboratory system, HSFA is a sequel to IHR progress, complement- and workforce received some funding but it was still ing JEE and NAPHS. Pakistan signed IHR (2005) on inadequate. The remaining 10 JEE technical areas re- June 15, 2007. In 2014 the MoNHSR&C designated the ceived very little or no funding, namely, IHR coordina- National Institute of Health as a focal point to oversee tion, reporting, medical countermeasures, risk commu- the implementation of IHR and notified the multi- nication, emergency response operations, food safety, sectoral national IHR Task Force to carry out a quick and preparedness. At the provincial level, 9 out of assessment of ten IHR core capacities. In 2016, Paki- 16 JEE technical areas received a significant budget, stan volunteered for the JEE exercise which assessed while 6 JEE technical areas received very low budgets, the country’s capacities to prevent, detect, and rapidly namely, zoonotic diseases, risk communication, AMR, respond to public health risks and identified capacity medical countermeasures, workforce development, gaps. The assessment resulted in the development of and preparedness. Many reasons could be attributed the NAPHS, which aims to address gaps pointed out to these disparities but most important is the lack of by the JEE and strengthen IHR core capacities in Paki- stewardship and commitment to increasing the health stan. However, the large gap in the 2016 JEE exercise security budget by the MoNHSR&C and its provincial was the lack of assessment on health security financing. counterparts. Hence, in 2021, Pakistan conducted the HSFA to fill gaps in the JEE exercise, complement IHR progress, At the provincial level, there is a wide disparity in and expedite NAPHS implementation by generating health security spending across JEE technical ar- evidence on the existing levels of financing for health eas. During the period of the HSFA (2017-2019), Pun- security. Further HSFA aimed at identifying approach- jab spent PKR 165.3 billion (covering 14 JEE technical es to prioritize health security investments within ex- areas), while Sindh spent only PKR 1.8 billion (cover- isting budgets, providing options for incremental do- ing 10 JEE technical areas) on health security. Health mestic resource mobilization, and making a case for security spending in other provinces was as follows: increasing investments in preparedness, response, and KPK PKR 6.6 billion (covering 8 JEE technical areas), recovery mechanisms. Balochistan PKR 4.7 billion (covering 7 JEE technical areas), GB PKR 2.5 billion (covering 6 JEE technical The HSFA found that Pakistan had spent areas), and AJK PKR 0.08 billion (covering 6 JEE tech- PKR 236.3 billion on health security activities nical areas). Annual per capita health security expendi- across 16 JEE technical areas during 2017-2019. ture also varies across provinces. While health security More than three-quarters of spending (PKR 181.97 spending in Punjab and GB was PKR 501 (US$3.98) billion) on health security was carried out at the pro- and PKR 694 (US$5.52) per capita, Sindh spent only vincial level and a quarter (PKR 54.33 billion) at the PKR 12 (US$0.09) per capita. Health security spending PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 70 FINDINGS AND RECOMMENDATIONS per capita in other provinces and federating areas was investment case. Similarly, preparedness activities need as follows: KPK PKR 63 (US$ 0.05), Balochistan PKR strengthening as the NHEPRN being the organization 130 (US$1.03), and AJK PKR 66 (US$0.36). to deal with the mandate of Emergency Preparedness and Response (EPR), is underfinanced and insuffi- According to the HSFA, developments and in- ciently staffed. vestments have been made in selected JEE tech- nical areas at the national level, but these are not Several actions are therefore needed to fully ex- consistent across all technical areas, with some ecute the IHR. A priority action area for Punjab is JEE technical areas being neglected. The JEE laboratory/biosecurity/biosafety capacity. At present assessment highlighted gaps in implementing IHR there are inadequate skills in these areas to maintain across the 19 JEE technical areas. In the last five years, an inventory of high-risk pathogens. There is weak some of the JEE technical areas have gained more IHR coordination within and across the country. A attention and resources than others, including AMR, food safety risk communication strategy does not exist. biosafety, immunization, laboratory, and surveillance. In Sindh, public health laboratory capacity in human In the area of AMR, the National Action Plan for AMR health is weak or nonexistent. There is no antimicro- and the Global Antimicrobial Resistance Surveillance bial resistance surveillance system with a lack of pub- System (GLASS) Pakistan has been developed along lic health reference laboratories at the provincial level. with the notification of provincial focal points to sup- KP province has the weakest biosecurity approach. port implementation. In the area of biosecurity, Paki- The district laboratories perform very limited testing. stan has formulated the National Biosafety & Biosecu- No formal multisectoral coordination mechanisms rity Policy and now there is a functional biosafety level currently exist. The biosecurity situation is essentially (BSL-3) laboratory at the national level. Immunization unknown with no inventory of dangerous pathogens. is the area that benefits most from reforms. National Gaps exist in immunization coverage across many dis- Immunization Technical Advisory Groups (NITAGs) tricts, and pockets of populations are undervaccinated, have been constituted for immunization. To ensure a namely, mobile, displaced, and hard-to-access groups. fully functioning vaccine supply, the Vaccine Logistics In Balochistan, there is lack of an effective sample Management Information System (VLMIS) is in place transport system and little or no point-of-care testing. across Pakistan. There have been major improvements There is no external quality assurance scheme or con- in diagnostics capacity to support timely detection, tingency for testing priority diseases except by sending prevention, and control of infectious diseases during samples to the NIH. The coordination mechanism like outbreaks and epidemics, including the establishment other provinces is at its lowest rank. No formal inter- of such state-of-the-art laboratories as Public Health sectoral coordination mechanisms exist for disease sur- Laboratories Division (PHLD) at the NIH Islamabad veillance and reporting for zoonosis, disease outbreaks, (referral lab) and the Microbiology Lab of the Institute and emergency response under a One Health approach of Public Health (IPH), Lahore. in all provinces. The current weak workforce develop- ment area must be strengthened to include sufficient Some JEE technical areas remain neglected and focus on public health concerns. require immediate attention. Some of the key JEE technical areas including point of entry, food safety, risk There is a lack of coordination between the communication and preparedness remain under-re- federal, provincial, and local governments and sourced. PC-I for point of entry has been approved stakeholders for implementing the IHR. For ex- but requires some time to get the funds released from ample, NHEPRN, under the MoNHS&C, and the the development budget. Presently, there exists no pre- National Disaster Management Authority (NDMA) cise and integrated system of monitoring and surveil- are both working on emergency response operations lance to mitigate health and economic losses associated (ERO), but no formal information-sharing mechanism with a substandard food safety system in Pakistan. A exists between these two departments. Further, there risk communication strategy has been developed but exists a lack of preparedness and responses in provinc- implementing it requires a financing proposal and an es to tackle emergencies and even nonemergency situ- 71 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 FINDINGS AND RECOMMENDATIONS ations. Similarly, NIH and NHEPRN have overlapping in the last 20 years, health expenditure has remained activities. below 1 percent till 2016, and currently, it is 1.2 per- cent of GDP. As a consequence, Pakistan’s health The IHR Task force is the only mechanism to im- expenditure per capita is very low, that is, US$42.87, plement IHR but its performance is less than ex- far behind the regional average of US$216.61. More- emplary. Pakistan became a member of IHR in 2005; over, a substantial portion of the health expenditure is nonetheless, ministries and line departments at the fed- nondiscretionary, that is, it cannot be appropriated for eral and provincial levels are unclear about their roles health security activities. The tax to GDP ratio is also and responsibilities. Therefore, the benefits of em- not promising when compared to other countries in bracing the One Health approach are not well-known. the region and earmarking taxes for health security is Coordination between ministries and line departments not in practice. responsible for the implementation of NAPHS is sub- optimal. The first meeting of the IHR Task Force was Various sources are used to finance health securi- held in 2017 and is second in mid-2021. ty at the federal and provincial levels, but the cur- rent health security financing arrangement is not Most of the planned interventions for IHR imple- sustainable. At the federal level, health security is mentation at the provincial level since 2017 have mainly financed through the development budget (86.3 either not started or are still incomplete, including: percent), followed by external sources (8.6 percent), own sources (3.8 percent), and the recurrent budget • Notification of Provincial IHR Task Forces (1.2 percent). At the provincial level, only two sources • Notification of IHR focal persons in health are used to finance health security i.e. regular budget and other sectors at the federal and provincial (63.4 percent) and the development budget (36.6 per- level cent). • Communication to the Chief Secretaries of each province for intersectoral coordination The HSFA also finds multiple constraints and lim- and resource allocation itations to the PFM process for health security. • Development of PC-I for key prioritized tech- These include: nical areas. • Periodic supervision to ensure activities are Input-based budgeting is one of the barriers to implemented according to target. financing health security expenditure. Under this • Recruitment and deployment of the required system, budget is allocated to entities like ministries, human resources for health security and One departments, divisions, etc. using the object elements Health at all levels. like salaries, operating expenses, etc. In this way, the funds cannot be allocated directly to JEE technical ar- As a consequence, the provinces are still not clear about eas, nor can the expenditure on JEE technical areas be their role in achieving the health security level required tracked from the government financial system. by IHR 2005. Provincial PC-I that assures sustainable financing for health security is pending and there is no The budget release process has caused under- provincial-level plan to allocate funds for the neglected spending for health security areas. Numerous JEE technical areas. Moving ahead the MoNHSR&C checks are built into the release process, resultantly, it should take a proactive role in implementing the mon- is subject to multiple controls and numerous checks, itoring activities as envisaged. which has made the budget execution cumbersome. The macrofiscal environment of the county is not Fragmented revenue is another issue for health conducive to supporting health security activities. -security financing. Financing from the health devel- High gross debt and chronic government deficit as a opment partners is usually not aligned with the gov- percentage of GDP are the main hurdles to raising ernment financial systems and cannot be easily traced. health security spending. Despite steady GDP growth As a result, estimating the fiscal envelope for health PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 72 FINDINGS AND RECOMMENDATIONS security is not feasible. that facilitates the committed engagement of relevant stakeholders, was not drafted. It is, therefore, recom- The budget approval process in the context of mended that the government of Pakistan should carry fiscal decentralization is another PFM issue. out actions as recommended by WHO to finance pan- Fiscal decentralization as a result of devolution is the demic preparedness at the national level. unfinished agenda of GoP. The 18th Amendment to the Constitution delegated most of the public service There is also a need to increase awareness on in- delivery functions to the provincial governments. As a vesting in health security and pandemic prepared- consequence, PFM became a hybrid system of rules, ness, as well as economic risks and returns, including regulations, and procedures for the federal as well as on making “health security is economic security” a re- the provincial governments. This system involves mul- ality at national and provincial levels. As clearly demon- tiple layers of checks and numerous officials engaged strated by the COVID-19 pandemic and previous pan- in budget execution, implementation, release process- demics, the costs associated with inaction and the lack es, etc. of pandemic preparedness is immense. Yet, shortly after each pandemic, governments and ministries of finance in many countries tend to become complacent 4.2 RECOMMENDATIONS and deprioritize-e investments in health security and pandemic preparedness, only to bring it back when The recommendations sections is organized based on the next pandemic occurs. Hence, there is a need for the sub-objectives of the study, that is, (i) making a continuous and persistent attention and investments business case for increasing investments in prepared- for health security and pandemic preparedness; and, ness, response, and recovery mechanisms; (ii) identify- the clear evidence that “health security is economic ing approaches to prioritize investments within existing security” is key to making the investment case. budgets; and (iii) providing options for incremental do- mestic resource mobilization. NAPHS revision at the provincial level should be pursued imediately. NAPHS was developed to Making a business case for increasing strengthen the IHR core capacities across Pakistan. A investments in preparedness, response, part of the NAPHS was the monitoring and evaluation plan to measure the progress in five years. However and recovery mechanisms in 2021, during the revision of NAPHS, 2021, it was observed that only 38 percent of funding was secured Developing a financing plan, investment case, and to implement the NAPHS at the federal level and there change management strategy is critical for achiev- is no formal mechanism to gauge the provincial im- ing IHR core capacities. WHO has recommended plementation of NAPHS. HSFA has now provided a stepwise process for investing in health security, and the actual expenditure on the 16 JEE technical areas at it needs to be pursued by the government of Pakistan. the federal and provincial levels from 2017-2019, it is, The first step i.e. conducting the JEE assessment has therefore, important to revise the provincial NAPHS. been implemented by Pakistan, as JEE assessment was The revision of NAPHS will help to identify the fi- conducted in 2016. Pakistan also follows through with nancing gap between the actual expenditure (HSFA) the next step of developing the National Action Plan and the desired expenditure. The NAPHS revision will for Health Security along with the costing estimates. produce indicative cost estimates to improve IHR im- However, Pakistan did not develop the financing pro- plementation in the coming years. posal, necessary to mobilize domestic resources and at- tract donor support for health security. Consequently, a Lastly, donor and development partner assistance, in- significant portion of NAPHS remained unfunded till cluding assistance from civil society organizations and 2021, and only one-third of activities were financed by the private sector, can improve investment in prepared- the government or through the assistance of develop- ness activities and provide supplementary resources. ment partners. Finally, a change management strategy For this the government needs to be able to effective- 73 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 FINDINGS AND RECOMMENDATIONS ly coordinate the use of external sources of funding, put-based and including IHR. In the medium-term, direct it to priority health interventions, and avoid the revised CoA should be linked with MTBF. The duplication. Medium-Term Budgetary Framework (MTBF) is an approach to budgeting that focuses on achieving the Identifying approaches to prioritize government’s medium-term goals and service delivery. However, the current MTBF set out the details of the investments within existing budgets budget by functional and object classifications of the Chart of Accounts. Revising the CoA would mean Prioritization of health security within the existing that the budget will be given an additional dimension budget requires working on the PFM reforms includ- i.e. budget allocation by JEE technical areas. This will ing, moving from input- to output-based budgeting, also affect The Budget Estimates for Service Delivery changing CoA to allocate an IHR-specific budget, and (BESD) which are referred to as the “Green Book” building the capacity of government staff to develop which specifies the purposes i.e. output and outcomes health-specific MTBF. expected to be achieved with funds appropriated. Fi- nally, the staff should be trained in implementing the One of the areas to prioritize investment in MTBF. IHR is moving from line item budgeting to program-based budgeting. Line item budgeting clas- sifies, organizes, and releases the budgets as per the en- Providing options for incremental tity (ministry and departments), or by the administrative domestic resource mobilization lines (salaries, travel, etc.). This limits the allocation of budget to JEE technical areas like AMR, surveillance, Some of the areas where the government can mobi- etc. This classification of budgeting also gives very less lize domestic resources are addressing inefficiencies managerial autonomy to the spending entities. Con- throughout the health system as well asmobilizing trary to this, program-based or output-based budgets additional resources for health from taxation. are closely aligned with the health sector priorities and make it easy to allocate and monitor the health alloca- Identifying and addressing inefficiencies in the tion by the program, services, or packages. As of today system. So far, no specific technical efficiency assess- the financial system of Pakistan is still working on line ment has been conducted; however, through the HSFA item budgeting and needs to be revised by changing qualitative assessment, there is anecdotal evidence of the Chart of accounts structure in the financial system. technical inefficiencies in health security spending, including the inability to spend the allocated budget Revising the existing CoA could lead to the pri- within the required timelines. This can be addressed by oritization of the health security budget. Revising introducing commitment accounting at the federal and the CoA structure best suited to fulfill the reporting provincial levels. This method will ensure full spending requirements of IHR must be on the cards. A compre- against the allocated budget. hensive desk review followed by in-depth interviews with the relevant stakeholders will help to refine the Earmarking taxes. Mobilizing resources from tax- CoA structure. Once finalized the revised CoA should ation, including imposing excise taxes on unhealthy be shared with the CGA to incorporate in IFMIS. Of- products and luxury goods, has proved to be an effec- ficers responsible for entering the expenditure data in tive method to increase resources for health in several IFMIS should be trained to enter the data using the countries. Pakistan still has room to further increase ex- new codes. Finally, a data extraction exercise should cise taxes on tobacco and unhealthy food products that be done to see if the revised CoA can report on JEE are high in fat, sodium, and sugar to increase overall technical areas. government revenues, and then allocate these resourc- es for health, through earmarking taxes. The MoNHSR&C and provincial departments of health should build their capacity to properly Creating domestic resources by reprioritizing re- develop and apply MTBF by making it out- sources from other sectors as well as within the PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 74 FINDINGS AND RECOMMENDATIONS health sector. High-income countries around the the entities refrain from procuring the health and labo- world are in better shape to prioritize health because of ratory equipment because of the fear the funds might their conducive macroeconomic conditions and ability not be released on time and they may have to face liti- to translate their GDP growth to increases in health gation by the suppliers. Furthermore, the first tranche allocation. However, there are some exceptions such as of the budget is usually released only around the end Madagascar and Malawi which have spent 14 percent of the first quarter or in the second quarter, and hence and 9 percent, respectively of their budgets on health, responsible units usually do not have a budget for im- despite being lower-income countries. One of the key plementation in the first quarter, leaving them with just reprioritization strategies used in lower- and middle-in- nine months out of a full fiscal year to implement. come countries is to introduce cost-saving interven- tions in their national health plans. With a restricted The delays in releasing the first tranche usually budget and competing priorities, the Government of contribute to delays in subsequent tranches. An imme- Pakistan could use allocative efficiency analysis among diate solution to this problem is to preferably release the various sectors to determine the reallocation of the first tranche within the first month of the fiscal funding from low-priority areas in other sectors to year to allow for a full year of implementation, and also health. There is also room to reallocate within the make an exception to the “30 percent-30 percent-40 health sector, by using cost-effectiveness analyses to percent policy” in case there are reasonable needs to help policy makers to reallocate funding from cost-in- release more than 30 percent of an annual budget in effective health interventions to cost-effective health the first quarter. There is a need to emphasize prioriti- interventions. To achieve this, there is a dire need for zation in the NAPHS document, according to nation- the health sector to acquire training and technicalskills al needs and achieving synergistic impact (investing in in allocative efficiency and cost-effectiveness analyses, AMR/IPC without enabling regulatory functions and as well as high-level political commitment and apply having access to quality medicines and microbiologi- them to policy. cal testing capacity, or investing in surveillance without functional public health labs). Some general recommendations include: The health sector may lead the process and provide Improving budget release processes. The federal technical guidance. However, IHR aspects and the and provincial governments tend to manage the ap- health security approach should be incorporated proved budget through a “mechanism of releases” into the national planning processes in all sectors for which significantly reduces the overall usefulness of ownership of non-health sectors. the budget as a tool to create fiscal discipline, economy, and transparency. The budget is released to spending There is a need to build capacities of national entities in three tranches, that is, 30 percent in the first systems and resources (for example, infrastructure, data quarter, 30 percent in the second quarter, and 40 per- systems, planning, financing, etc.) to increase cover- cent in the third quarter. This release process in effect age of the minimum package of prioritized life-sav- works against procurements to support health security ing health services (preventive, curative, palliative, and and health services. In many cases, payments for pro- rehabilitative) based on the PHC approach to reduce curement cannot be made in a piecemeal fashion. For health risks and prevent, prepare for, and respond to instance, when equipment is required to be purchased epidemics/pandemics and other health emergencies. in one go, then the invoice has to be processed for the whole of the equipment. In such cases, the procuring agencies are not authorized to spend the whole of the budget for the physical asset in the first quarter. If they opt to wait two or three quarters, this reduces the utili- zation of the budget in the first quarter, which attracts objections by MoF for non-release of funds in the sec- ond and third quarters. Due to this process, at times 75 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 FINDINGS AND RECOMMENDATIONS PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 76 ANNEXES 05. Annexes 77 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 ANNEXES ANNEX 1: LISTS OF STAKEHOLDERS Federal PUNJAB Health Service Academy Expanded Program on Immunization (EPI) National Institute of Health TB Control Program Punjab Expanded Program on Immunization (EPI) AIDs Control Program Punjab National Health Emergency Preparedness Malaria Control Program & Response Network CDC Program Punjab Directorate of Central Health Establishments IRMNCH Program Punjab Pakistan Environmental Protection Agency Nutrition Program National Veterinary Lab Hepatitis Control Program Punjab Pakistan Agricultural Research Council ICP Financials National Agricultural Research Center Agriculture Department Punjab Livestock Wing Environment Department Punjab Livestock Department and Dairy Development Department Sindh Expanded Program on Immunization (EPI) MNCH Program AJK Hepatitis Program Department of Health AJK Tuberculosis Control Program Expanded Program on Immunization (EPI) AJK Malaria Control Program Polio Department ADP scheme Public Health Laboratory LHW Program Malaria Control Program AJK Prevention & Control Program for Dengue Field Epidemiology & Surveillance Regular Scheme Field Epidemiology Lab Training Avian Pandemic influenza NHEP & RN National Program for Prevention Planning Department Economic Affairs Industries Department Livestock PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 78 ANNEXES Development Partners KP WHO Expanded Program on Immunization (EPI) European Union HIV/AIDs Control Program Public Health England (PHE) Malaria Control Program CDC TB Control Program FAO Polio Eradication FELTP Fisheries Department UNICEF IDSR WFP MNCH Program WB LHW Program USAID National Program for Family Planning DFID Environment Protection UNFPA Livestock Department IDB Forest Department JICA Wildlife Department UNDP Industries and Commerce ADB JSI 79 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 ANNEXES GB Balochistan Expanded Program on Immunization (EPI) Expanded Program on Immunization (EPI) Law Department TB Control Program Gilgit-Baltistan Environment Protection Agency MNCH Program Fisheries Department Gilgit-Baltistan Malaria Control Program Parks & Wildlife Circle Gilgit-Baltistan LHW Program Forest Department Gilgit-Baltistan Livestock GB (Human) Livestock GB (Animal) National Program for FP-PHC GB Directorate Food GB GB - DMA TB Control Program GB MNCH Program GB Directorate of Industries, Labour & Commerce Health Department DG Office Finance Department PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 80 ANNEXES ANNEX 2: NOTIFICATION OF A MULTISECTORAL NATIONAL IHR TASK FORCE 81 PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 ANNEXES ANNEX 3: RE-NOTIFICATION OF A MULTISECTORAL NATIONAL IHR TASK FORCE PAKISTAN HEALTH SECURITY FINANCING ASSESSMENT 2021 82 REFERENCES 07. 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