Privatisation in reproductive health services in Pakistan: three case studies

Abstract

Abstract

Privatisation in Pakistan's health sector was part of the Structural Adjustment Programme that started in 1998 following the country's acute foreign exchange crisis. This paper examines three examples of privatisation which have taken place in service delivery, management and capacity-building functions in the health sector: 1) large-scale contracting out of publicly-funded health services to private, not-for-profit organisations; 2) social marketing/franchising networks providing reproductive health services; and 3) a public-private partnership involving a consortium of private players and the government of Pakistan. It assesses the extent to which these initiatives have contributed to promoting equitable access to good quality, comprehensive reproductive health services. The paper concludes that these forms of privatisation in Pakistan's health sector have at best made available a limited range of fragmented reproductive health services, often of sub-optimal quality, to a fraction of the population, with poor returns in terms of health and survival, especially for women. This analysis has exposed a deep-rooted malaise within the health system as an important contributor to this situation. Sustained investment in health system strengthening is called for, where resources from both public and private sectors are channelled towards achieving health equity, under the stewardship of the state and with active participation by and accountability to members of civil society.

Résumé

La privatisation du secteur de la santé pakistanais s'inscrivait dans le programme d'ajustement structurel lancé en 1998 après la crise aigüe de liquidités du pays. Cet article examine trois exemples de la privatisation qui a touché les fonctions de prestation de services, gestion et renforcement des capacités dans le secteur de la santé : 1) sous-traitance de la prestation de services financés par les fonds publics à des organisations à but non lucratif ; 2) réseaux de franchise sociale assurant des services de santé génésique ; et 3) partenariat public-privé réunissant un consortium d'acteurs privés et le Gouvernement pakistanais. Il évalue dans quelle mesure ces initiatives ont contribué à promouvoir un accès équitable à des services de santé génésique complets et de qualité. L'article conclut que ces formes de privatisation ont, au mieux, assuré la disponibilité d'une gamme limitée de services de santé génésique fragmentés, souvent de qualité sous-optimale, à une fraction de la population, avec de médiocres avantages pour la santé et la survie, en particulier des femmes. L'analyse met en lumière un malaise profondément enraciné dans le système de santé qui a contribué sensiblement à cette situation. Des investissements suivis sont requis en faveur du système de santé où les ressources des secteurs public et privé doivent être canalisées en vue de garantir l'équité dans la santé, sous l'administration générale de l'État et avec la participation active et le contrôle des membres de la société civile.

Resumen

La privatización en el sector salud de Pakistán fue parte del Programa de Ajuste Estructural iniciado en 1998 tras la aguda crisis de divisas. En este artículo se examinan tres ejemplos de privatización que han ocurrido en las funciones de prestación de servicios, administración y desarrollo de capacidad en el sector salud: 1) la contratación en gran escala de organizaciones sin fines de lucro para la prestación de servicios financiados públicamente; 2) la prestación de servicios de salud reproductiva por parte de redes de franquicias sociales; y 3) la alianza de los sectores público y privado, que consiste en un consorcio de actores particulares y el gobierno de Pakistán. Se examina hasta qué grado estas iniciativas han contribuido a promover acceso equitativo a servicios integrales y de buena calidad de salud reproductiva. Se concluye que estas formas de privatización en el sector salud de Pakistán, como mucho, han hecho disponibles una limitada gama de servicios de salud reproductiva fragmentados, a menudo de calidad subóptima, a una fracción de la población, con pocas recompensas en salud y supervivencia, especialmente para las mujeres. Este análisis expuso un malestar profundamente arraigado en el sistema de salud como un importante contribuidor a esta situación. Es imperativo continuar fortaleciendo el sistema de salud y canalizar los recursos de los sectores público y privado hacia lograr equidad en salud, bajo la administración del Estado y con la participación y responsabilidad de los integrantes de la sociedad civil.

Key Words:

• reproductive health policy and programmes
• privatisation
• social franchising
• public-private partnerships
• Pakistan

Privatisation of public sector health services may be defined as the transfer by a government of ownership and/or government functions from public to private for-profit or not-for-profit organisations. Privatisation may happen in one or more of the government's functions, including financing, service delivery, capacity-building, management and investment.¹

As has happened in many low-income countries, privatisation of Pakistan's health sector was influenced, among other factors, by a severe foreign exchange crisis (in 1998), loans from international financial institutions and the “recommendations” that came with them. In 1998, the World Bank's health care strategy paper on Pakistan made a series of recommendations for increasing the role of the private sector in health care.² Legislative and institutional changes followed, which contributed to a reduction in the state's role in the health sector.

This paper examines the extent to which privatisation has contributed to equitable access to good quality, comprehensive reproductive health services in Pakistan. Equity in access to health care refers to equal access to a basic package of services for equal need, where “need” refers both to the “capacity to benefit”^* and the “severity of illness”; and “access” refers to the barriers, mainly financial and geographical, faced by potential users.³ The dimensions of quality examined in this paper are basic adherence to asepsis and infection control, and appropriate training and technical competence of health providers. Comprehensive reproductive health services include services for maternal health (including delivery care and emergency obstetric care), contraception and abortion, infertility, reproductive tract and sexually transmitted infections, breast cancer, cancers of the reproductive system, and education and counselling on human sexuality and reproductive health.⁴

Information used in this paper is from published and web-based sources in English, identified through Google and Medline searches using the following keywords with specific reference to Pakistan: “privatisation health”, “contracting health”, “provider networks health”, “social franchising” “equity access delivery care”. Websites of all major bilateral and multilateral donors and US-based international non-governmental organisations (NGOs) working on reproductive health were then searched, and relevant project descriptions and evaluation reports found were used.

Privatisation in Pakistan's health sector

Pakistan's health sector is characterised by woefully inadequate health resources in terms of personnel, infrastructure and per capita health expenditure, contributing to high mortality and poor health outcomes (Table 1). The physician:population ratio (2000–09) was only 8 per 10,000 population, and there were only 4 nurses and midwives (taken together) per 10,000 population, and 6 hospital beds per 10,000 population. Comparable average figures for lower middle income countries are 10 physicians, 14 nurses and midwives and 39 hospital beds per 10,000 population. Pakistan's under-five mortality rate was 89 per 1,000 in 2008, and its maternal mortality ratio in 2007–08 was 276 per 100,000 live births, both higher than the average for lower middle income countries.⁵

short-legendTable 1

Financing of Pakistan's health sector has been predominantly from private out-of-pocket expenditure by households, which accounted for 70% of total health expenditure in 2007. Donor funding contributed to 3.5% of total health expenditure while government spending on health accounted for 26.5%.^{5 *}

The government health delivery system ranges from outreach services at the community level and basic health units providing preventive and curative care to tertiary care hospitals providing specialised and referral services, located mainly in big cities and coming directly under the provincial Secretary of Health.² There is a large informal private health sector (as compared to formal), including traditional birth attendants who conduct a significant proportion of all deliveries.² The formal private health sector includes small and medium-sized hospitals and maternity homes as well as government-employed physicians and paramedics running clinics after office hours. The not-for-profit sector in health consists mainly of NGOs providing family planning and other reproductive health services.⁶

Privatisation in Pakistan's health sector was part of the overall project of privatisation of the economy that started in 1998. Pakistan carried out its nuclear tests in 1998 and had economic sanctions placed upon it as a consequence. The country plunged into a serious foreign exchange crisis because investment flows, as well as bilateral and multilateral aid, decreased sharply. The World Bank, International Monetary Fund and Asian Development Bank provided loans to help Pakistan out of its crisis, in addition to rescheduling bilateral as well as commercial loans. In turn, the country was required to implement a Structural Adjustment Programme, which included privatisation of the economy.⁷

In the same year, the World Bank produced a health care strategy paper for Pakistan that recommended restricting public sector involvement in health to provision of pure “public goods” and full cost recovery for all other services, to be introduced in a phased manner. Another important recommendation was that the health sector should enter into partnerships with the private sector for technical support as well as provision of government-financed health services. The paper specifically recommended handing over a major part of the responsibility for reproductive health services to NGOs on output-based contracts, funded by government, and entering into contracts with private providers for delivery of services.²

A number of policy and legislative measures followed in the Punjab and Khyber-Pakhtoonkhwa (erstwhile North West Frontier) provinces soon after the strategy paper was released. Teaching hospitals were given greater “autonomy”, inter alia to set their own fee schedules, in order to become more viable financially. In addition, user fees were put in place in all health institutions in the public sector. In Punjab, Khyber-Pakhtoonkhwa and other provinces, the government also contracted out the management and service delivery functions of public health facilities to NGOs. The government also entered into partnerships with international and national NGOs and bilateral donors for technical support in management and service delivery. Social franchises were established to promote health service delivery by private health providers. Each of these interventions had implications for reproductive health services.

This paper examines three case studies of privatisation of service delivery and/or management and training in the health sector and assesses the extent to which each of these has contributed to equitable access to good quality, comprehensive reproductive health services.

Three case studies

• Contracting out publicly-funded services to the private, not-for-profit sector

One of the well-known experiments in contracting out publicly financed health services to private not-for-profit organisations in Pakistan is the Chief Minister's Initiative on Primary Health Care. A pilot was launched in one district of Punjab province, Rahim Yar Khan, in March 2003. The district government entered into a memorandum of understanding with the Punjab Rural Support Programme, a national NGO,^* to manage all of the 104 basic health units in that district.⁸ By the end of 2003, the pilot was extended to 12 districts, and in 2005 to 23 districts in the province.⁹ In 2007, the newly elected federal government initiated the People's Primary Health Care Initiative, based on the Rahim Yar Khan model, which now operates in 69 districts of four provinces in Pakistan.¹⁰

The Chief Minister's Initiative on Primary Health Care has been operational for several years and is the only such initiative in Pakistan that has been evaluated. According to the Memorandum of Understanding, Punjab Rural Support Programme was given administrative and financial control and authority over all basic health unit buildings and equipment, and received from the government the same amount of money monthly as was previously allocated for running these units. They were to provide basic curative services and co-ordinate with front-line workers to provide maternal and child health, family planning and other preventive and health promotion services.⁸

Punjab Rural Support Programme introduced a number of innovations. It clustered 2–3 basic health units together and placed them under the charge of a single medical officer. The medical officers' salary was increased from Rs 12,000 to Rs 30,000, and they were required to live close to their area of work. A district project management unit was responsible for the management of all basic health units within the district. Physical infrastructure was improved by securing additional funding from the district government. Women medical officers were recruited on an experimental basis in one sub-district of Rahim Yar Khan, and each served five basic health units.¹¹

Three evaluation studies of the Chief Minister's Primary Health Care Initiative, carried out in 2005,⁸ 2006¹¹ and 2009,¹² are available. Each used a slightly different methodology, but all were based on primary data collection from the facilities and users. The 2009 study included interviews with key informants from the health sector.

The first two evaluations found that there was a significant increase in utilisation of basic health units because the facilities remained open at regular hours and drugs were available, which was not previously the case. Because basic health units serve rural areas, this may be seen as increasing equity in access to services.^8,12

However, there were important gaps in the availability of reproductive health services.^8,12 The 2006 evaluation found that, although basic health units were meant to provide maternal and child health, family planning services and curative care for gynaecological problems, they were only providing antenatal care and some delivery and post-partum care. Deliveries could be conducted only till 2:30 pm daily, the closing time for basic health units. Most basic health units did not have the equipment to carry out even normal deliveries and women medical officers often brought their own instruments. Only a few reproductive health-related tests were carried out, such as pregnancy tests. Even basic haemoglobin estimation tests were not available. Contraceptive supplies and services were not available, nor post-abortion care, in any of the Punjab Rural Support Programme facilities in Lahore district. The programme did not maintain data on maternal mortality or morbidity or on reproductive health conditions for which treatment or care was sought.¹²

The only information on quality of services is from the 2005 study, which reported that drug availability, quality of provider-client relationships and quality of clinical care were poor in both the contracted-out basic health units of Rahim Yar Khan district and the government-run basic health units in a control district.⁸

The 2009 study compares different primary health care “models” in Pakistan and provides insights into the difficulties faced by the Punjab Rural Support Programme. Non-integration of national programmes at the basic health unit level posed a major problem. Family planning, for example, was a vertical programme directly administered by the federal Ministry of Population Welfare, while immunisation was part of another vertical programme under the federal Ministry of Health. Project managers of the Punjab Rural Support Programme had no authority over the staff of these programmes. This affected the delivery of preventive and health promotion services through basic health units, including contraceptive services.¹¹

Secondly, there was little cooperation on the part of government health managers with the Punjab Rural Support Programme in matters such as approving additional posts, filling vacancies, and ensuring drug availability. District health officials appear to have been at best indifferent, and at worst hostile, to the Punjab Rural Support Programme, because they perceived the programme to have been implemented top-down without them being adequately consulted. One government health manager said in a key informant interview that, given the same magnitude of resources and authority (as the Punjab Rural Support Programme had) they (government health department) would be able to manage the basic health units better. Another person said that the problem of large-scale movement of medical professionals from the public to the private sector was the reason for poor performance of basic health units and that contracting out did not solve this problem. He drew attention to the further fragmentation of health service delivery between basic health units managed by private NGO providers and secondary hospitals managed by the government health department. For example, referral mechanisms between the two had not been streamlined, compromising continuity of care for clients.¹¹

There were also difficulties in team building at the level of the basic health unit. Paramedical and administrative staff whose salaries had not been increased resented the three-fold increase in medical officers' salaries.¹¹

We did not find information on whether steps have been taken to address these difficulties in the Punjab province. If not, then the wisdom of hasty expansion of the model, with an annual expenditure of about 270 million Pakistani rupees (roughly US$30 million)¹⁰ may be questioned.

• Social marketing/franchising networks

Social franchise programmes in health in low- and middle-income countries have consisted mainly of networks of private medical practitioners or other health providers offering a standardised set of services under a shared brand. The brand name serves as a guarantee of the availability of a defined package of services that are meant to signify high quality, at clearly determined prices. They may remain as networks or evolve into franchising programmes in which there is a controlling, franchiser organisation that provides ongoing monitoring and technical support to the franchised providers.¹³

Green Star Marketing and Key Social Marketing are two major social franchising networks of private providers in Pakistan, engaged in providing what they call reproductive health services. DFID and USAID are estimated to have spent annually UK£1.5 million and US$10 million, respectively, in supporting these networks in 2003–2009,¹⁴ in addition to out-of-pocket spending by service users to purchase products and services from their health facilities.

Green Star Marketing

Green Star Marketing Pakistan (originally called Social Marketing Pakistan) was started as a USAID-supported project of Population Services International (PSI), and in 1991, became a non-profit local NGO. Green Star Marketing in 2010 markets a total of 17 products, including oral contraceptives, condoms, injectables, emergency contraceptives and IUDs in the urban areas of all but a few of the 105 districts of Pakistan's four provinces.¹⁵

Four types of health providers are included in the Green Star Network: male and female private medical practitioners, pharmacists, and female health visitors. Each of these groups receives training from Green Star Marketing on reproductive health and all contraceptive methods.¹⁶ Women doctors are trained in the provision of contraceptive services, including IUD insertion and prescribing hormonal contraceptives. Since 2001, some women doctors have been trained to provide female surgical sterilisation services.¹⁵ Male doctors are expected to motivate men to take responsibility for family planning and to support their wives when they choose to adopt a method. Pharmacists are expected to counsel and guide low-income people, who tend to consult a pharmacist before visiting a physician. Female health visitors – women who make home calls or run small private clinics – are expected to provide counselling services and non-clinical methods of contraception. They usually serve the poorest neighbourhoods and also refer women to the women doctors in the network.¹⁶

Franchisees receive products marketed by Green Star at a subsidised cost. Green Star also provides its franchisees access to new medical techniques, management support and advertisement of the brand. The Network has grown to over 17,000 private sector providers in 40 cities throughout Pakistan.¹⁷ A new intervention to promote contraceptive use was started in December 2005. Married women of reproductive age living within a radius of 5 km from a Green Star health facility were approached in their homes and motivated to attend the Clinic Sahoolat, held once in six months, to receive free family planning services from a trained Green Star provider.¹⁸

In 2006, Green Star Marketing became a partner of the PAIMAN consortium (see next section) and set up “GoodLife” clinics to provide maternal and child health care in addition to contraceptive services.

Key Social Marketing

Key Social Marketing is funded by DFID through the Futures Group International, a US-based social marketing organisation. The Futures Group has joined with two pharmaceutical companies to market their oral, emergency and injectable hormonal brands under a social marketing logo – the Key – but at commercial (non-subsidised) prices.¹⁹

Contraceptive counselling, Punjab, Pakistan

Franchisees of Key Social Marketing include doctors, female health visitors, pharmacists and selected NGOs. This social franchising programme involves a very large network, with 10,000 doctors in private practice, 25,000 pharmacists, 1,000 female health visitors and selected NGOs operating mainly in urban areas of the country.²⁰ Key Social Marketing's community workers provide information on contraceptive methods to low-income women through Mohalla Sangat (women's group meetings at the community level).¹⁹

Evaluations of both networks

Both Green Star Marketing and Key Social Marketing have been evaluated by donors more than once. Evaluation reports and studies show that these franchising networks have increased access to contraceptive services.¹⁷ Compared to non-franchised private health facilities, these franchised facilities had a significantly greater volume of total clients as well as clients for contraceptive services.²¹

Since both franchising networks have made major efforts towards community outreach, one might expect that coverage of low-income groups would be high. However, available data present a mixed picture. An early (1997) evaluation of the Green Star Network found that 74% of Green Star clients were from low-income groups, albeit from urban areas,²² and a 2000 study found that 90% of Key Social Marketing clientele were low-income women.¹⁹ However, a 2004 study of social franchising for reproductive health services in three countries, including by Green Star and Key Social Marketing in Pakistan, reported that both these franchised establishments had become associated with a wealthier clientele in the intervening years, which may have been a consequence of the franchised facilities being located mainly in urban areas.²¹

The range of services provided by both franchising networks is extremely narrow. Green Star Marketing was supposed to provide a comprehensive package of reproductive health services, not only contraception but also post-abortion care, syndromic management of STIs, antenatal and post-partum care, emergency obstetric care, and neonatal care. In practice, they provide mainly contraceptive services. Other reproductive health issues were rarely discussed with clients and there were no IEC materials on other reproductive health issues. Key Social Marketing promotes only oral and injectable contraceptives, both its own branded products. No other sexual or reproductive health service is provided.¹⁸

Reports of evaluations of both networks in 2006 dwell extensively on the poor quality of services provided. The problem may have its roots in the uneven and sometimes sub-standard quality of provider training. The 2006 evaluation report¹⁸ narrates how the trainer demonstrating insertion of the multiload IUD, a product provided by Green Star, was “contaminating disposable ‘clean’ gloves, touching insertion instruments, failing to swab vagina and cervix with antiseptic solution before sounding of the uterus and insertion of the Multiload”. In Key Social Marketing, training was sub-contracted to four organisations, and with so many trainers involved, the quality of training could not be standardised.¹⁸

The quality of counselling in Green Star clinics was also not very good.¹⁸ For example, not enough information was given about side effects of contraceptives. There was also a tendency to push clients towards choosing the IUD over other methods. Interviews with husbands of clients revealed that the husbands were concerned about the fact that their wives were having health problems related to use of IUDs. While the cost of getting contraception was only between Rs 35–50, the cost of gynaecological treatment for dealing with side effects, including secondary infertility, could be higher than Rs. 2000. The same report¹⁸ also observed that home visits by workers of Key Social Marketing to give information and to counsel women had turned into a routine and mechanical activity consisting of playing the Key's informational audiocassettes and then clarifying any doubts.

Lack of adherence to asepsis was noted as a problem in both networks. Green Star providers were observed as not adhering to infection control practices. Many clinics covered by the evaluation had unprepared instruments. Autoclaves remained locked up, implying that they had rarely been used. Hand-washing before and after wearing gloves was not practised by providers.¹⁸ On one specific day when a Clinic Sahoolat was taking place in a Green Star clinic:

“The doctor was busy with her routine [out]patients… [the paramedic] took the client for IUD insertion. After examining the client it was found that there were no instruments on the trolley… [the paramedic] started searching for instruments in the cupboard with the gloves on her hands. Meanwhile the client was lying exposed on the couch and pulled her own shawl on her exposed body due to embarrassment… the instruments (which were eventually located) were soaked in tap water in a kidney dish… While adjusting the size of the Multiload the thread came out of the adjusting tube and the Multiload and thread were on her [paramedic's] hands. When suggested to use a new Multiload the suggestion was ignored and the same IUD was inserted into the woman's uterus.” ¹⁸

Infection prevention in clinics of Key Marketing Services with qualified women doctors met quality standards, but this was not the case in clinics where providers had only basic training and were not all medical doctors. Many women coming to these clinics suffered from reproductive tract infections.¹⁸

• Pakistan Initiative for Mothers and Newborns

Another large-scale project funded by USAID is the Pakistan Initiative for Mothers and Newborns (PAIMAN), implemented through a consortium led by USAID's consulting agency JSI Research and Training Institute, Inc. PAIMAN's mandate is to assist the Government of Pakistan to improve the status of maternal and newborn health in Pakistan “through viable and demonstrable initiatives”.²³

The PAIMAN consortium consists of nine partners: JSI and three other US-based international consulting organisations, two universities and three Pakistan-based NGOs, including Green Star Marketing.²⁴ Started in 2004 in ten districts in the four provinces of Pakistan, the project in 2010 covers 24 of 105 districts in the four provinces, and four agencies (equivalent to districts) of the Federally Administered Tribal Areas.^{25 *} The project period was extended from five to six years ending in September 2010, and the total budget for the six-year project is reported to have been US$92 million.²³

PAIMAN undertook the following key interventions for improving access to maternal and child health services: establishing health facilities to provide maternal-neonatal health and contraceptive services in urban areas through public-private partnerships; developing a cadre of community midwives and helping them establish community-based birthing centres; training traditional birth attendants to improve the quality of maternal health care; provision of ambulances; renovating health facilities; and training government health providers in essential surgical skills and life support. Though the project had three levels of indicators (outcome, output and activity level), only activity and output data have been used for reporting and monitoring progress.²⁵

Information on achievements of project targets is available from a mid-term evaluation of the initial ten project districts²⁶ and from the annual report for the year October 2008–September 2009.²³ Two studies carried out in 2009 of the training of community midwives and traditional birth attendants evaluated the quality of training.^26,27

The mid-term evaluation reported that in the initial ten project districts, five of six project targets were met between 2005 and 2008. Births assisted by traditional birth attendants increased from 36% to 38%; women who received three or more antenatal visits increased from 27% to 35%; pregnant women who received at least two doses of tetanus toxoid during the most recent pregnancy increased from 40% to 43% (target not met); women who had a post-partum visit within 24 hours of giving birth increased from 34% to 39%, and facilities upgraded and meeting safe birth and newborn care quality standards increased from 0 to 26.²⁵

According to the 2008–09 annual report, project targets were fully achieved for almost all 86 output indicators reported for the period 2004–2009. The one exception was deployment of 50 ambulances for community-based emergency transport. Not a single ambulance had been deployed during the first five years; this was scheduled to happen in the sixth year of the project.²³ During 2004–09, 600 franchised “GoodLife” clinics with private providers were set up by Green Star Marketing; 3,020 women benefitted from Clinic Sahoolats; infrastructure in 31 government health facilities was improved to enable provision of maternal and newborn health services; 714 government health providers went through refresher training in midwifery skills; 2,140 traditional birth attendants were trained to provide clean delivery care; and 1,623 women were enrolled in a new 18-month course for community midwives.²³

But output indicators may not tell the whole story. One example is the achievement of the target of upgrading 31 government health facilities, of which 18 were upgraded to provide comprehensive emergency obstetric and newborn care. According to the mid-term evaluation in 2008, comprehensive emergency obstetric and newborn care facilities in four of the ten districts were constrained in providing the requisite services because of shortage of staff, non-resident staff who were not available after 2 pm and shortages in blood supply. Providers interviewed reported that magnesium sulphate, a life-saving drug for managing eclampsia and pre-eclampsia, was not available in any of these centres. There was also a shortage of antibiotics in some facilities. In 2008, comprehensive emergency obstetric and newborn care facilities served only 6.6% of the women who had obstetric complications in the project districts. Whether the situation subsequently improved remains to be seen from the end-line evaluation.²⁵

The training of 550 private providers who were to run “GoodLife” clinics was also evaluated in 2008. The training did not include a clinical practicum. Use of partograph and active management of third stage of labour – both essential skills for safe delivery – were not included in the training curriculum. The report also remarked on the non-availability of data from many “GoodLife” clinics on whether delivery or emergency obstetric care were being provided.²⁵

The mid-term evaluation commented on the management challenges posed by PAIMAN's consortium structure, and the high number and geographic spread of activities. Staff of partner organizations were not seconded to the project and therefore did not constitute a stable project team. Also, the abundance of partners led to a complex division of labour and poor coordination in some activities. For example, four partners were implementing behaviour change communication activities at different levels and in different locations, and four partners were responsible for training of different cadres of health providers on a range of topics.²⁵

Evaluation of trained traditional birth attendants and community midwives found them wanting in skills essential for providing quality pregnancy and delivery care. A 2009 evaluation of the training of traditional birth attendants (TBAs) under the PAIMAN project compared 275 birth attendants randomly assigned for training in maternal and newborn health with 274 similarly assigned for training in general health. The evaluation found that the trained (in maternal-newborn health) TBAs did much better than the control group in terms of knowledge and skills. However, a majority of trained TBAs lacked important skills. For example, less than half of them checked the size of the uterus during antenatal abdominal examination or checked for the baby's movement, and less than a third checked the baby's heartbeat.²⁶

Community midwives' training was also evaluated in 2009 through an assessment of 174 community midwives who had passed their examinations in 2008 or early 2009.^{27 *} Sixty-nine of the 174 community midwives (40%) were not resident in their respective communities at the time of the evaluation, although each of them was to have established a midwifery home in their communities after completion of the course. The evaluation remarks on the huge waste of resources this represents and recommends improving the recruitment strategy. The knowledge and skills of 106 community midwives from six districts, all of whom had been given equipment to start midwifery homes, was assessed. Only half the trainees had completed the training requirement of conducting 15 or more deliveries. None of the six districts completely fulfilled the standards of training for each community midwife. Respondents fared poorly when assessed for knowledge of danger signs during pregnancy, delivery and post-partum, with not even one of the 106 community midwives able to identify all the danger signs included in the curriculum. While most could identify anaemia in women, only one-third could carry out a complete abdominal check-up of a pregnant woman, and only 9% of the community midwives could correctly perform all seven specific steps in conducting a normal delivery.²⁷

PAIMAN has taken many steps towards promoting equity in access to maternal health care. First, it works in a few locations of the Federally Administered Tribal Areas, an area with poor health infrastructure and coverage. Second, it has invested in capacity-building for government health professionals in emergency obstetric care, creating a cadre of community midwives who will serve rural communities, and training traditional birth attendants. Third, it has upgraded health facilities to provide comprehensive emergency obstetric and newborn care. Fourth, it has successfully established urban clinics run by private providers and providing services at subsidised costs.

Despite these commendable efforts, information currently available raises doubts as to whether they have translated into improved access to maternal health care for women. The quality of training of community midwives and traditional birth attendants is inadequate. Several health facilities upgraded to provide comprehensive emergency obstetric care are unable to provide these services owing to health system failures. It remains to be seen whether the quality of care in “GoodLife” clinics and their outreach programmes is significantly better than that observed in the mid-term evaluation in 2008 and earlier evaluations of Green Star's clinics. In view of these facts, one cannot but wonder whether the outcomes justify the outlay of more than US$15 million a year.²³

Other concerns include ownership of value and accountability of the project. Project leadership is vested in an international NGO and is accountable to the donor. Members of civil society and even residents of the districts within which the projects are operational may have limited say in decisions about what activities are undertaken, where and by whom, although these interventions are in the government sector.

More will no doubt be known after the end-line evaluation to afford a more comprehensive assessment of the contributions of PAIMAN in assisting the Government of Pakistan in improving maternal and newborn health status in the country.

Discussion and conclusions

The health sector in Pakistan is under-resourced both in terms of infrastructure and human resources. Out-of-pocket expenditure in health is the largest source of health financing, and accounted for 70% or more of total health expenditure for the decade 1998–2009. It is against this backdrop that rapid privatisation is happening. On the one hand, services in public facilities are substantially privately financed through user fees; on the other, government is funding NGOs to run its health facilities in large parts of the country through its People's Primary Health Care Initiative. Social franchising networks of private providers account for a third of contraceptive services provided in the country. The PAIMAN consortium headed by an international NGO and funded by USAID, although operating in less than a fourth of Pakistan's districts, is an important player in influencing availability, access to and quality of maternal and newborn health services.

Has access to good quality, comprehensive sexual and reproductive health services been improved through privatisation in Pakistan?

In terms of availability, social franchising networks have provided mainly contraceptive devices and to a lesser extent, sterilisation services; antenatal care, and to a lesser extent, delivery care. Basic health units contracted to NGOs were not providing contraceptive services in some districts because it was the responsibility of the Ministry of Population Welfare, indicating a failure of coordination between sectors. Availability of delivery services was also rather poor. PAIMAN focuses on antenatal and delivery care, but excludes contraceptive services. Because many health providers trained by PAIMAN have failed to gain essential skills for providing safe delivery and emergency obsteric care, de facto availability of delivery services may not have increased to the extent planned. There is no mention of provision of any of the other reproductive health services in the literature found. Services for men, single women and adolescents are conspicuous by their absence. Availability of reproductive health services in the government sector may be further constrained by responsibility for health and population shifting to the provinces following a constitutional amendment in early 2010. Anecdotal evidence indicates that Balochistan and Khyber Pakhtoonkhwa do not consider reproductive health and family planning a priority and are inclined to allocate few resources for them (Personal communication, Khawar Mumtaz, Shirkat Gah, Karachi, Pakistan).

In terms of equitable access, strengthening basic health units which serve the rural population is a step in the right direction, but will not achieve better access unless there is better coordination between various programmes and levels of the health sector. Social franchising clinics are concentrated in urban areas and not accessible to the majority of women living in rural areas. One study²¹ found that Pakistan's franchised clinics cater to relatively wealthier clients. The unresolved problem of using the “for-profit” sector, including commercially operated social franchises, to expand coverage is that they have only a limited interest in populations who have hitherto not been reached, that is, those who are also unable to pay and those living in rural and economically under-developed areas, where the demand for services that have to be paid for will be low. PAIMAN's attempts to increase access to basic and emergency obstetric care seem to be floundering due to staff and resource constraints and management issues within the public sector. It is too early as yet to know how successful this project will be in increasing access, especially to the poorest and most marginalised groups of women.

Evaluation reports on the franchised clinics raise serious concerns about the quality of care provided. The choice of contraceptives is limited, and infections due to lack of universal precautions is worrying. As for PAIMAN's upgraded comprehensive emergency obstetric care facilities, absence or non-use of essential life-saving drugs such as magnesium sulphate, limited availability of blood products, non-existence of standard referral procedures for obsteric complications, as reported in the mid-term evaluation, are major failings that could fail to prevent maternal deaths and morbidity. The sub-standard quality of PAIMAN's training of private providers, traditional birth attendants and community midwives is likely to result in poor quality pregnancy and delivery care unless corrective re-training and hand-holding are implemented, a costly proposition.

Based on the limited but damning evidence available, it can be said that privatisation in Pakistan's health sector is not delivering good quality, comprehensive reproductive health services. Instead, privatisation has created a limited range of fragmented services of often sub-optimal quality, available mainly to urban dwellers, and giving poor returns in terms of women's reproductive health needs.

One lesson to be drawn from these case studies is that it is not possible to tinker with and improve a limited section of the health system while leaving unaddressed deep-rooted systemic malaise, including: issues of staffing and remuneration; availability of equipment and supplies; and lack of coordination between health programmes, different tiers of health facilities and different government departments. These pose major hurdles to making health facilities functional at any level, irrespective of who runs them. Similarly, difficulties faced by PAIMAN and the social franchising networks in ensuring good quality training and patient care cannot be seen in isolation from the quality of pre-service training of health professionals and the absence of quality assurance mechansims within and across the health sector.

In sum, there are no shortcuts to achieving equitable access to good quality, comprehensive reproductive health services. Sustained investment in strengthening the health system needs to happen under government stewardship. In this, public and private resources must be channelled to achieve health equity, within a cohesive policy framework in which the public and private health sectors work in tandem, not at cross purposes. Such reforms would be part of a political agenda that balances economic growth with equity, and happens with the active participation of and accountability to civil society, the public and patients.

Acknowledgements

This paper is a shorter, modified and updated version of a report entitled “Privatisation in health services and implications for sexual and reproductive health services: a case study of Pakistan”, prepared for and with funding from ARROW (Asia-Pacific Research and Resource Centre for Women), Kuala Lumpur, Malaysia, as part of its ICPD+15 monitoring project. Some parts of this paper have also appeared in an article entitled “Privatisation in SRHR: glimpses from some countries in South and South-East Asia. Arrows for Change 2009;2&3:4–6.

Notes

* “Capacity to benefit” refers to the extent to which health services benefit a population group. Populations with relatively good health are expected to have a more limited “capacity to benefit” as compared with those who are in poorer health. Capacity to benefit may also vary in two population groups with the same “level” of health when one population's health problems are more amenable to health service interventions than the other's.³

* Figures for the proportion of health expenditure by government are based on the revised WHO estimates in World Health Statistics 2010.⁵

* The Punjab Rural Support Programme appears to be a quasi-government body rather than a civil society organisation. It was registered in 1997 with a start-up endowment fund provided by the Punjab government. Three of its 12 board members are from government and the majority of its personnel, including the Chief Executive Officer, are officials seconded from government departments.¹⁶ (p.33)

* In addition to the four provinces with 105 districts, there are four federally administered territories, of which the Federally Administered Tribal Areas is one; it is divided into seven tribal agencies and six smaller frontier regions.

* According to the project's annual report for 2008–09, 1,150 students were enrolled during the three years 2006–08 in the course for community midwives.²⁴ However, in the evaluation report, only 174 community midwives were reported to have completed the course by mid-2009. The reasons for this huge discrepancy are not clear.