After devolution of the Ministry of Health by the Federal Government to the provinces under the 18th Amendment, on June 30, 2011, health responsibilities/institutions were placed under the jurisdiction of the following government ministries/divisions:
c. International Health Regulations
5. Inter Provincial Coordination
a. Central Health Establishment
b. Pakistan Medical and Dental Council
c. Nursing Council
d. Homeopathy Council
e. Tibb Council
f. Pharmacy Council
To improve governance on health issues, on May 4th, 2013, the federal subjects in health scattered in various divisions were consolidated under the newly established Ministry of National Health Services Regulation and Coordination (MoNHSR&C).
This report highlights the performance of the Ministry since its inception and its role in steering the Health System of Pakistan by assuring access to quality medical services, providing framework for health policies and enforcement of the same through improved regulatory functions at the national level. At the same time it ensures alignment with the International Health Regulations thus enhancing the country’s responsiveness to the emerging health issues at a global level.
The mission of the Ministry is to regulate and coordinate efficient, effective and equitable, health and population welfare services in the country.
The performance of the Ministry is reported in the following sub-sections:
Ensuring Transparency and Merit
The Ministry is currently headed by Mrs. Saira Afzal Tarar as Minister of State. Under her stewardship, as a first step immediate measures to mitigate corruption in the system were taken. Good Leadership entails designing strategic policy frameworks combined with effective oversight, coalition building, enforcement of appropriate regulations and incentives, system design and accountability. The following steps were taken in this regard:
1. Posting of honest qualified and competent officers against key positions
2. Eradication of culture of corruption and politicization of institutions
3. Merit based decision making and fiscal discipline
4. Purging key organizations of lobbies and vested interests
Key positions filled included Director General, Health; Director Malaria; National Program Manager, Expanded Program on Immunization; National Program Manager, National AIDS Control Program; Chief Executive Officer, Drug Regulatory Authority Pakistan (DRAP); and, Director Pricing DRAP.
Establishment of Coordination Mechanisms in the New Ministry
Once competent human resources were placed at key positions, the mechanisms to ensure accountability were reviewed and steps taken to establish them. In this regard an exercise to reorganize the Ministry to ensure robust structures in order to support its coordinating and regulatory functions was undertaken. Coordinating Mechanisms with line Ministries, Provinces and development partners that were abolished after devolution were revived. The Ministry successfully established two forums specifically for this purpose, namely
1. Interprovincial Health & population ministerial forum
2. Donor coordination & Harmonization forum
In addition two units were operationalized in the Ministry. The Non Communicable Diseases (NCDs) Unit was established to tackle growing challenges of diseases like diabetes, heart ailments, mental health and cancers in the country.
The Communicable Disease Unit for existing (EPI, HIV, Malaria, TB) and emerging threats (Ebola, Congo fever, others) was made functional and aligned with national and international activities, the role of the Unit primarily being that of coordination and centralizing data/information.
Drug Regulatory Authority
The Ministry strengthened the Drug Regulatory Authority by successfully appointing CEO of DRAP on merit through a transparent and competitive process.
In addition Comprehensive Drug Pricing Policy was finalized for the first time after extensive consultation with all stakeholders. The backlog of Licensing and Registration Applications was significantly reduced and regular processes were put in place on “first in first out” basis. Alternate Medicine Sector too was brought under Regulatory Ambit through notification of Alternate Medicine Enlistment Rules 2014. Transparency was introduced in the procurement process as well. In this regard the Annual Procurement Plan was placed on PPRA website. To further improve efficiency SoPs (Standard operating Procedures) for all processes were prepared and displayed on PPRA website.
Certain steps to improve quality of medicines were taken. In collaboration with WHO the Ministry initiated capacity building workshops for Pharmaceutical companies to promote current good manufacturing practices (cGMP). Campaigns against spurious/fake drugs have concurrently been started.
International Health Regulations (IHR)
IHR mechanisms have been strengthened as per international requirements to ensure rapid and comprehensive response to emerging infectious disease threats.
Laboratory facilities have been upgraded to international level (e.g. Pakistan First Bio Safety Level 3 Laboratory stands established which had been pending since 2008). This has now enabled Pakistan to diagnose rare and dangerous diseases like Ebola, Congo, MERS-Corona and Avian influenza virus etc.
Following the International pressure, Pakistan implemented IHR polio related travel requirements within a short period of one month in early 2014. The MoNHSRC coordinated vaccination and reporting of about 27,000 daily outbound travelers at points of exit (air and sea ports) and other facilities. WHO has recognized these efforts and appreciated the rapid implementation of these measures in Pakistan.
The emerging new challenge of prevention and control of Ebola virus in Pakistan in 2014 was planned and implemented successfully. The National Ebola preparedness plan was prepared in August 2014 immediately after WHO declaration. Coordination with Aviation, Interior, Provincial health departments and WHO led by the Ministry was commendable. The SOPs for air and sea ports, isolation facilities, diagnosis, treatment and burial practices were prepared and trainings implemented all over the country within a short span of time. Simultaneously Rapid Response teams were organized and implemented. All suspected cases of Ebola were tracked and managed according to international guidelines. The WHO mission expressed appreciation on excellent coordination by MoNHSRC.
Prevention and Control of Diseases
Field Epidemiology & Disease Surveillance Division
Field Epidemiology & Disease Surveillance Division was established in 2014 which was non-existent earlier. The unit will take a lead in disease surveillance and provide technical support to provinces. The five provincial rapid response units established for coordination are already showing improvement in data quality.
National Blood Policy 2014-20
New National Blood Policy 2014-20 has been formulated in consultation with Provinces and Islamabad Blood Transfusion Authority. The body has been reactivated to ensure availability of safe blood, free of infections. Under this initiative construction of 10 Regional Blood Centers and up-gradation of 60 blood banks across the country is underway.
A Comprehensive Multi-Year Plan (cMYP) 2014-18 for immunization was developed in consultation with all Provinces and partner agencies. The plan ensures sustained availability of resources and brings clarity for future planning at national and provincial level. National Immunization Policy finalized in consultation with stakeholders from provinces and partners, will ensure adoption of international best practices in this field.
Robust Anti-Measles campaign was completed across the country targeting 62.4 Million children from 6 months to 10 years of age. Web based Vaccine Management system has been introduced. In 56 districts, the system is functional and is ensuring tracking and monitoring. This has significantly reduced vaccine wastage. Free Pneumococcal vaccine has been provided for the first time across the country to protect 6 Million children against Pneumonia.
Vaccine Security and Management
Over 86% increase in production of anti venom sera (e.g. anti snake and rabies) by the NIH was achieved through better management practices. The Ministry ensured uninterrupted supply of vaccination for: 34 million children during Polio campaigns; 6 million children and 6 million pregnant women against 9 deadly and debilitating diseases by mobilization of resources in EPI. Wastage of the polio vaccine reduced from 15 to 11 % through introduction of vaccine and logistics management system.
Emergency Coordination Centers for polio coordination at federal and provincial levels stand functional now and have resulted in improved campaign quality, swift response to emerging coordination issues and availability of joint platform for all stakeholders’ review. An independent third party evaluation after a lapse of many years has been completed which will further improve campaign quality. On the administrative front, the pending PC 1 for Polio eradication approved in 2014 with adequate resources till end of 2015, has been secured from IDB. After a gap of 3 years due to extensive coordination efforts of the Ministry, Pakistan Army and partners, polio campaigns in North & South Waziristan have resumed. Mechanisms in the polio program to address the challenge of security threat to polio workers have been establishment with robust linkages with affiliated departments to ensure the security of staff. Under the Cabinet Committee on Immunization with Minister for Interior, Minister for Defence and Minister for NHSR&C as members, a new threat perception system has been put in place which links up with district polio planning process. These efforts have resulted in improving the coverage of the campaign especially in FATA agencies and 11 KP districts. The success is also attributed to the successful collaboration with armed forces under UAE PAP Project, a new initiative. In addition, introduction of injectable polio vaccine for the first time in high risk areas, is another step which has both increased coverage as well as quality of campaigns.
National Programs (Malaria, TB and HIV/AIDS)
The national programs were revived in the Ministry to ensure effective coordination role among provinces and partners. In this regard, National & Provincial Strategic Plans for T.B. Control have been developed. Free of cost diagnosis and treatment through a BSL3 lab network at 1,257 T.B. care facilities has been resumed.
By 75% increase in early diagnosis and prompt treatment in Malaria Diagnostic and Treatment Centers, reduction in deaths caused by malaria has been achieved. Alone, 34% reduction in Malaria Disease burden has been seen due to Robust Preventive measures including Vector Control and Behavioral Change Communication.
18 new HIV/AIDS Treatment centers have been established which have provided treatment to 5,034 HIV cases in 2014 as against 2,588 in 2013 (95% increase).
Non Communicable Diseases (NCDs) Unit
MNHSRC in collaboration with WHO is committed to develop a national plan of action to combat and control NCDs. Provincial and national units have been established for the first time in Pakistan. National and provincial consultations have been carried out to review the problem in detail. New pictorial warnings on cigarette packs and increase in tobacco taxation has been achieved by efforts of the Ministry.
Prime Minister’s National Health Insurance Program
A landmark in achieving universal health coverage is the National Health Insurance Program launched under guidance of the Prime Minister by MoNHSRC. Millions of poor will be able to access quality health care services under the Program. The program design, benefit package, actuarial inputs, monitoring mechanisms and preparations for roll out have been completed in record time with provinces and line Ministries. On the request of Minister of State MoNHSRC a high level WHO mission and GIZ, assisted Pakistan to undertake this initiative, and expressed satisfaction on the level of preparedness and ownership by the Ministry.
The PC-1 is with the Planning Commission at the final review stage.
Policy and Legislations
The Ministry has focused on Legislation and Policy framework establishment. Legislation for Federal Health Regulatory Authority is in final stage which will ensure quality of health service delivery in federal territories. Similarly new Legislative bills on HIV AIDS, Immunization and Health Insurance are under process at various stages. Necessary amendments pending since long in Pakistan Medical and Dental Council, Pharmacy, Health Research Council and DRAP acts are now in final stages.
National mentorship program from evidence to policy, has been initiated by MoNHSRC with Global Alliance for Policy Research, WHO, to train young professionals in the area of health policy development.
Pakistan’s Representation at the International Health Forums has been commendable. Pakistan has won the bid to host next Regional Conference of WHO EMRO region scheduled end of 2015, an honor which will be coming to Pakistan after almost 20 years due to efforts of the Ministry at regional level.
Pakistan has won a place in the GAVI Board after 6 years; this will allow the country to have a voice at highest international forum meant for vaccine and immunization funding.
In addition Pakistani delegations participated actively and effectively in international health forums like World Health Assembly, Regional meetings, IHR committees and bilateral forums.
The following new major grants and funding were won by Pakistan in health sector during last 2 years due to efforts of the federal MoNHSRC in addition to other ongoing grants:
• Global fund for TB, HIV and Malaria 110 million USD
• GAVI for new vaccines, IPV and cold chain 130 million USD
• UAE PAP (Polio ) 30 million USD
• Government of Japan support for Polio 5 million USD
• World Bank for immunization support 50 million USD
• Govt of China Bill Gates Foundation and others contributed equipment and in kind support to MNHSRC worth millions of USD
Research and Development
The area of research and development was steered by the Ministry and the following outputs are reported:
1. Demographic Health Survey – This credible survey was completed in 2013 and is now successfully guiding policy and planning in health and population
2. Global Youth Tobacco Survey of Pakistan – led to focused legislation to minimize tobacco use in youth and enhanced awareness campaigns.
3. Malaria Indicator Survey – Informed malaria control program to address key gaps. Findings of the survey are being used for applying for Global fund grant .
4. Burden of Non Communicable Diseases Survey- The data will be used to predict future disease trend, health services needs and planning future strategies.
5. Strengthening of Institutional capacity for research – Institutions of Ministry have initiated doctorate and masters programs in health sciences & research and have produced progressively increasing numbers of research papers
Regulatory functions (Doctors, Nurses, Pharmacists, Homeopaths and Hakims)
PMDC Reforms Committee was constituted to streamline functioning of PMDC and issues related to foreign medical graduates, quality of medical colleges and regulation of profession in an efficient manner. Management Information Systems for Registration of Nurses has been successfully launched for easy access and improved efficiency. The National Examination Unit for Nurses has been developed. Finalization of criteria for appointments of teachers by Pharmacy Council is seen as a vital step in improving pharmacy education and appropriate steps in this regard are being initiated. Unani Tibb Pharmacopia pending for last 40 years was published in 2014; an important milestone achieved to ensure standardization of unani medicine.
Population Policy Framework has been developed and shared with the Provinces. The National Task Force has been constituted to Coordinate and Review Health and Population Welfare Program of the Provinces and Special Areas. Realization of Pakistan’s International commitments in the area of Population Planning are in progress. Consultations with all Provinces towards Contraceptive Commodity Security have been completed.
The Ministry has had to face many challenges since its inception. The main challenge was to redefine roles and responsibilities after 18th constitutional amendment. This was viewed as a challenge and an opportunity. It provided the Ministry a chance to begin afresh and to be innovation and propose out of box strategies. However, barriers as low investment in health sector, scarcity of human resource, lack of credible data and information and sub optimal performance of health systems at grass root level, have substantially affected the progress.
The following roadmap has been laid by the Ministry for the coming year:
1. Model Pharmacy Project to improve access to cheaper generic medicines in Islamabad (2015).
2. ISO certification of Ministry of National Health Services, Regulations and Coordination (2015)
3. Mentorship program for young professionals in Ministry of NHSR&C (2015)
4. Pilot project to improve Blood quality in Federal areas (2015)
5. Establishment of state-of-the-art Medical University in Islamabad with assistance of Government of Bahrain (project starts in 2015)
6. Establishment of a national data base to inform Policy and Planning in Health (2015)
7. Introduction of new vaccines
a. ROTA virus vaccine for diarrhea (2016)
b. Hepatitis additional dose at birth (2015)
c. Injectable Polio vaccine in Routine EPI (2015)
8. Establishment of Public Health and Nursing University in public sector offering higher degrees in related disciplines.
9. Establishment of Cancer Hospital in Islamabad – Budget allocated as part of PSDP
10. Indigenous production of vaccines to meet national requirement; initiation of Public Private Partnership through EOI to be
floated internationally (Government to Government)
11. Mentorship program for young professionals in Ministry of NHSR&C
12. Campaign for improving Blood quality in Federal
13. Campaign for improving food quality in Federal Capital Territory
Prevention and control of communicable diseases
Bio-Safety Level Lab BSL-3 made functional in January 2014
National TB program
- National & Provincial Strategic Plan developed
- Free of cost diagnosis and treatment through a BSL3 lab & network at 1,257 TB care facilities
- MDG targets on track
- 34% reduction in Malaria Disease burden
- 75% increase in Malaria Diagnostic and Treatment Centers
Safe Blood Transfusion project
- Established 18 HIV/AIDS Treatment centres, 7 Prevention of Parent to Child Transmission (PPTCT) Centers and 15 Community and Home Based Care sites (CHBC) (50% Increase)
- Treated 5,034 HIV against 2,588 in 2013 (95% increase).
- New National Blood Policy 2014-20 and National Strategic Framework 2014-20 May-June 2014
- Construction of 10 Regional Blood Centers & up-gradation of 60 blood banks nearing completion Nov 2014
- Procurement of Equipment & MIS for 10 RBCs and 60 HBBs Nov 2013 – Sept 2014
Anti-snake Venom Serum produced
- Reactivation of the Islamabad Blood Transfusion Authority (IBTA) Sept. 2013
Vaccine management, field monitoring and supervision
- 86.12% increase by 30th June (26,331 Vials produced) between July 2013-June 2014
Vaccine Security and Management:
- Uninterrupted supply of vaccines for 34 million Children (polio) and 6 million Children (EPI) against nine vaccine preventable diseases and 6 million pregnant woman
- vLMIS initiated through USAID assistance helping tracking of vaccines in 54 high risk districts
- Vaccine Management Committees at all levels to monitor
- Wastage for Polio campaigns reduced from 15 to 11%
Cold Chain Equipment:
- Provision of free Pneumococcal vaccine across the country-October 2013
- Injectible Polio Vaccine (IPV) proposal accepted by GAVI and grant secured
Provision of high quality and affordable drugs:
- Equipment worth approx. USD 10 M (Chinese assistance)
- 87 Solar refrigerators in pipeline through JICA support
Window operation and E-office:
Drug Manufacturing Licenses & Renewals:
- Bringing alternative medicine in regulatory ambit
- Process for automation for applications of registration, licensing, pricing etc. in DRAP thereby decreasing human interface initiated
- Certification of Pharmaceutical companies for cGMP by WHO/FDA initiated to exploit full benefit of GSP plus status and enhanced market access
International Health Regulations:
- Reforms process initiated in DRAP
- One window operation for all applications
- All backlog cleared along with new applications which were disposed off expeditiously.
- Formulation of Pricing Policy ,
- cGMP rule s notified
IHR Requirements for Designated Airports, Ports and Ground Crossings:
- NIH designated as National Focal ‘Point’ & Primary Focal ‘Person’ notified (June 2014)
- Acquired capacity for lab diagnoses of MERS-Corona Virus & H7N9 Influenza viruses
- Essential services in placed at 11 entry points
- Established Polio counters and Ebola virus disease related information Desks at point of entries
- Full implementation of Polio related travel regulation
- Standard Operating Procedures for Polio related travel regulations developed and issued to all Provincial Governments
- 27000 daily outbound passengers vaccinated
- Ensuring lifting of travel regulations through optimal implementation
- Proactive Approach to provide Technical Guidance to Provincial Governments
- Guidelines for Prevention and Control of EVD
- Guiding notes for collection, storage and shipment of Ebola specimens
- Recommended Standard Infection Prevention & Control Precautions for EVD Transmission
In 2013 PMRC conducted 03 important surveys which previously were done by the NGOs/Private institutions. These included:
- Global Youth Tobacco Survey of Pakistan
- Malaria Indicator Survey
- Burden of Non Communicable Diseases Survey
Largest and most credible survey PDHS 2012-13 successfully accomplished and is guiding policy and planning in health and population