Background and Introduction
Bhore Committee constituted in 1945 was entrusted to conduct a health survey and subsequently lay down recommendations1 to improve health status of the people of Subcontinent. The recommendations made by this Committee are an important milestone in the history of public health of Indo-Pak. A shift from medical care to comprehensive health care was the cornerstone of the recommendations. The recommendations envisaged almost all the principles of today’s Primary Health Care (PHC) and provided a framework to plan health services on the basis of population.
Immediately after independence, the pace of health care planning and development remained slow. In the 1970s, health care planning and development gained momentum when a number of new medical colleges were established and the health budget was doubled. National health policy was promulgated, cornerstone of which was generic drug scheme with rural/urban and preventive/curative bias.
However, in 1978, Pakistan signed Alma-Ata Declaration, which adapted primary health care (PHC) as an approach to Health for All (HFA). During the 1980s, Basic Health Services Project and Primary Health Care Project laid down framework for Minimum Service Delivery Standards (MSDS), again on the basis of population. The health infrastructure was expanded so that each Union Council had a Basic Health Unit (BHU) and at each Markaz/ Thana level Rural Health Centre (RHC) was established. Similarly a Tehsil Headquarters Hospital (THQH) and District Headquarters Hospital (DHQH) were established at each Tehsil and District headquarters respectively
Minimum Service Delivery Standards - Basis
While designing and proposing Minimum Services Delivery Standards, Burden of Disease (BOD)3 in conjunction with population could be a realistic approach, as it gives reasonably good estimate of the basic health needs of a population. BOD helps in determining health needs of the population which in turn determine the nature of services to be provided at all levels of care. Services must be prioritized to maximize the benefit of health scarce resources. While prioritizing among the type of services, cost and non-cost factors and more importantly equity must be given due consideration. At the same time services must be pro poor and take seriously into account the issue of equity.
Once services are in place, the next logical and important question is the quality of care that cannot be achieved without defining standards.4 The standards have two principal objectives5. First, they provide a common set of requirements applicable to whole health care system and secondly they provide a framework for continuous improvement in overall quality of care. Ultimate impact of the MSDS would be to provide effective and healthy work force for the economic development of the country.
The MSDS not only address minimum services package and standards of care to be made available at all levels, but also envisages mandatory requirements/ system specifications to ensure the delivery of quality health care services6. These will also create conducive working environment for health care providers. MSDS would strive for a need-based system of care putting public first and focusing on quality health services. (Conceptual Framework of MSDS is given in Figure below)
Burden of Disease
The BOD measures the losses of healthy life in the form of disability and premature death due to all episodes of disease and injuries occurring in a given year. The BOD has historically been defined using two measures: morbidity and mortality. Morbidity describes the number of cases resulting from a particular disease or health problem. Mortality describes the deaths resulting from a particular disease entity or health problem. Both of these measurement schemes have weaknesses. To address these problems, Disability Adjusted Life Years (DALYs) have been promoted as a new burden of ill-health classification scheme. The main attraction of DALYs is that it combines morbidity and mortality measures into one metric.
An analysis of the BOD in Pakistan conducted in 1996 indicated that almost 40 % of the total BOD was due to poverty related communicable diseases (like tuberculosis, malaria, vaccine preventable diseases of childhood) and 12 % to reproductive health problems. More than one third (37.7%) of BOD was contributed by non-communicable diseases and nutritional deficiencies accounted for a further 6 % .