Health Administrative System in SAARC Nations: Challenges Ahead

Dr Upendra Singh (PhD, NET, MPA, MPH)

Ex Technical Consultant (Public Health), Ministry of Health & Family Welfare, New Delhi, India.

Abstract:

The South Asian Association for Regional Cooperation (SAARC) is an economic and geopolitical organization of South Asian nations. It was established on December 8, 1985 by India, Pakistan, Bangladesh, Sri Lanka, Nepal, Maldives and Bhutan. In April 2007, at the Association's 14th summit, Afghanistan became its eighth member. It plays the role of a guiding force for the member countries. SAARC provided a platform for the peoples of South Asia to work together in a spirit of friendship, trust and understanding based on mutual respect, equity and shared benefits. SAARC nations cooperation are in the area of agriculture, rural, biotechnology, culture, energy, environment, economy and trade, finance, funding mechanism, human resource development, poverty alleviation, people to people contact, security aspects, social development, science and technology, communications, and tourism. The paper attempts to study the existing Health Administrative System in SAARC Nations and analyze the challenges that may be faced by South Asian nations in health systems.

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Keywords: SAARC Nations, Health Administrative System, Health Systems, Challenges

1.?? Introduction:

The South Asian Association for Regional Cooperation, or SAARC, is an economic and geopolitical organization that was established to promote socio-economic development, stability, and welfare economics, and collective self-reliance within its member nations. Founded during a summit in 1985, SAARC’s initial members include Bangladesh, Bhutan, India, Maldives, Nepal, Pakistan, and Sri Lanka. Due to rapid expansion within the region, Afghanistan received full-member status and countries are considered observers. SAARC respects the principles of sovereign equality, territorial integrity, and national independence as it strives to attain sustainable economic growth.

The South Asian Association for Regional Cooperation (SAARC) is the regional intergovernmental organization and geopolitical union of states in South Asia. Its member states are Afghanistan, Bangladesh, Bhutan, India, the Maldives, Nepal, Pakistan and Sri Lanka. SAARC comprises 3% of the world's area, 21% of the world's population and 3.8% of the global economy.

SAARC was founded in Dhaka on 8th December 1985. Its secretariat is based in Kathmandu, Nepal. The organization promotes development of economic and regional integration. It launched the South Asian Free Trade Area in 2006. The objectives of the Association as outlined in the SAARC Charter are: to promote the welfare of the peoples of South Asia and to improve their quality of life; to accelerate economic growth, social progress and cultural development in the region and to provide all individuals the opportunity to live in dignity and to realize their full potentials; to promote and strengthen collective self-reliance among the countries of South Asia; to contribute to mutual trust, understanding and appreciation of one another's problems; to promote active collaboration and mutual assistance in the economic, social, cultural, technical and scientific fields; to strengthen cooperation with other developing countries; to strengthen cooperation among themselves in international forums on matters of common interests; and to cooperate with international and regional organizations with similar aims and purposes.

Decisions at all levels are to be taken on the basis of unanimity; and bilateral and contentious issues are excluded from the deliberations of the Association.

2.?? Review of Literature:

The South Asian societies have been passing through a critical phase confronting with the problems of acute poverty, high population explosion coupled with health care issues, ethnic and political conflicts. In order to meet these challenges, the South Asian Countries, are jointly working through active collaboration and mutual assistance amongst Member States. Focus on social issues under the broad heading of Health and Population Activities were one of the five original areas of cooperation identified by Member States during the inception of SAARC.

The Tenth Summit (Colombo, July 1996), while reviewing the progress made in the social sector, determined the need to develop, beyond national plans of action, a regional dimension of action including a specific role for SAARC with a view to speeding up social development in the region. It, therefore, decided to adopt a Social Charter incorporating a broad range of targets to be achieved across the region in the areas of poverty eradication, population stabilization, empowerment of women, youth mobilization, human resource development, promotion of health and nutrition, and protection of children.

?At their Twelfth Summit (Islamabad, January 2004), the Leaders signed the SAARC Social Charter. The provisions laid down in the Social Charter are now being implemented across the region with the establishment of National Coordination Committees (NCCs) in all Member States.

The Second Meeting of the Heads of National Coordination Committees (New Delhi, 6-7 September 2007) to implement the SAARC Social Charter made specific recommendations for its implementation, including thematic listing of areas of cooperation. Among all the areas of cooperation the Health and Population Activities in SAARC identified as an important area.

I. ????SAARC Tuberculosis and HIV/AIDS Centre (STAC):

Initially, a SAARC Tuberculosis Center (STC) was established in 1992 to support Member States in the prevention and control of tuberculosis in the region by coordinating efforts of national programmes. The centre was renamed as SAARC Tuberculosis and HIV/AIDS Centre (STAC) in 2005.

II???? SAARC Health Ministerial Meetings:

Emergency Meeting of SAARC Health Ministers (Maldives, April 2003)

First Meeting of the SAARC Health Ministers (New Delhi, 14-15 November 2003)

Second Meeting of the SAARC Health Ministers (Islamabad, July 16 2005)

Third Meeting of the SAARC Health Ministers (Dhaka, 26 April 2006)

Fourth Meeting of the SAARC Health Ministers (Male, 10-12 April 2012)

Fifth Meeting of the SAARC Health Ministers (New Delhi, 08 April 2015)

Sixth Meeting of the SAARC Health Ministers (Colombo, 29 July 2017)

III.??? ?Technical Committee on Health and Population Activities (TC HPA):

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-????????? The First Meeting of the Technical Committee on Health and Population Activities, under RIPA (Regional Integrated Programme of Action) was held on November 8-9, 2005 at Dhaka. The committee reviewed the progress of agenda implementation of the health ministers’ meetings.

-????????? The second Meeting of the Technical Committee on Health and Population Activities held in Kathmandu on May 5-6, 2008, discussed the project concept notes on Maternal and Child Healthcare and Immunization.

-????????? The Third Meeting of the Technical Committee on Health and Population Activities was held in New Delhi on July 30-31, 2009. This Meeting emphasized the common challenge of communicable diseases in the region and urged implementation in the national level.

-????????? The Fourth Meeting of the Technical Committee on Health and Population Activities was also held in New Delhi on 06 April 2015. The Meeting discussed various health related matters/projects and recommended interalia;

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a.????? Setting up of Expert Groups for Vector Borne Diseases (Malaria/Dengue/Chikangunya and others) with particular attention to Malaria.

b.????? Setting up an Expert Group/Consultative Group on Hepatitis

c.?????? Hold an annual meeting on Non-Communicable Diseases (NCDs)

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IV.?? Pursuant to the directive of the Twelfth SAARC Summit, SAARC Regional Strategy on HIV and AIDS (2006-2010) was developed along with a regional work plan for implementation of the Strategy.

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V.? During the Thirteenth Summit, the Prime Minister of India had proposed establishing a collaborative healthcare project involving a regional Telemedicine Network.

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VI.??? Communicable Diseases, Disease Surveillance and Pandemic Preparedness:

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The SAARC Expert Group Meeting to Develop SAARC Regional Strategy on Communicable Diseases was held in Paro, Bhutan from 7-8 July 2008. The Fourth Meeting of the SAARC Health Ministers held in the Maldives on 12 April 2012 launched the SAARC Regional Strategy on Communicable Diseases.

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3.?? Health Administrative System in SAARC Nations:

Article IV of the Social Charter of the South Asian Association for Regional Cooperation (SAARC) considers Health as one of the important area of cooperation. In which it is stated that;

??????? i.??????????????????????? States Parties re-affirm that they will strive to protect and promote the health of the population in the region. Recognizing that it is not possible to achieve good health in any country without addressing the problems of primary health issues and communicable diseases in the region, the States Parties agree to share information regarding the outbreak of any communicable disease among their populations.

???? ii.??????????????????????? Conscious that considerable expertise has been built up within the SAARC countries on disease prevention, management and treatment, States Parties affirm their willingness to share knowledge and expertise with other countries in the region.

?? iii.??????????????????????? Noting that the capacity for manufacture of drugs and other chemicals exists in different countries, States Parties agree to share such capacity and products when sought by any other State Party.

?? iv.??????????????????????? Realizing that health issues are related to livelihood and trade issues which are influenced by international agreements and conventions, the States Parties agree to hold prior consultation on such issues and to make an effort to arrive at a coordinated stand on issues that relate to the health of their population.

????? v.??????????????????????? States Parties also agree to strive at adopting regional standards on drugs and pharmaceutical products.

3.1?????? Afghanistan:

Afghanistan faces a significant challenge to creating a functional medical system in a post-conflict setting (although Afghanistan may be considered an “intra”-conflict setting). A low-income country recovering from decades of strife, the health care system has been in disarray for many years. Rebuilding the health care system in Afghanistan is currently being undertaken by a number of groups, including the Afghan government, and the US government. Since the defeat of the Taliban in 2001, medical services in Afghanistan have been provided mostly by NGOs contracted through the Ministry of Public Health.

Despite all the challenges, some progress has been made in rebuilding the Afghan medical system according to the Center for Disaster and Humanitarian Assistance Medicine, particularly in emergency medicine. Currently the plans for emergency services in Afghanistan are limited to the military sector. The focus on civilian health care is on primary care services, but as these improve, the long-term goal is to advance emergency care in the civilian sector as well.

There are many barriers to creating an accessible, effective, and sustainable health care system in Afghanistan. The main challenges of rebuilding Afghanistan’s health care system include a lack of security, lack of infrastructure, economic hardship, poor coordination among government and health care providers, difficult access to health care facilities, unsuitable hospital conditions, and lack of trained health care workers, especially women.

3.2?????? Bangladesh:

The provision of basic health services in Bangladesh is a constitutional obligation of the Government (IGS, 2012). Article 15 of the Constitution stipulates that it shall be a fundamental responsibility of the State to secure for its citizens the provision of the basic necessities of life, including food, clothing, shelter, education and medical care. The health sector has developed policies and programmes which are implemented through the central control of the Ministry of Health and Family Welfare.

There are four key actors that define the structure and functioning of the broader health system: Government, the private sector, NGOs and donor agencies. Government, the private sector and NGOs are engaged in service delivery, financing and employing health staff; donors play a key role in financing and planning health programmes.

The Ministry of Health and Family Welfare implements its programmes and provides services through different executing and regulatory authorities. The executing authorities include five Directorates of the Ministry and some other organizations. The Ministry of Health and Family Welfare regulates both public and private sector health services. The Ministry has been empowered to act as the central body for policy formulation and planning, regulating the medical profession and standards, managing and controlling drug supply, administering medical institutions, providing health services and much more. The Ministry, with its two wings of Health and Family Planning, manages public sector health services ranging from primary to tertiary care (excluding urban primary care), stretching from the central level to the grassroots and covering both rural and urban areas. Service coverage by the private sector is wider than the public sector.

There are number of factors played important roles in hindering expected improvement in the overall health status of the country.

-????????? the complexity of the mixed health systems and poor governance;

-????????? inadequacy of health resources and impact on quality of care;

-????????? inadequate and uneven health service coverage;

-????????? health-care financing through catastrophic OOPP by households; and

-????????? inequitable access to health services hindering universal health coverage

3.3??? ???Bhutan:

The predominantly public financed and managed health system in Bhutan has evolved and grown remarkably in the past five and a half decades. Health services are available through a three-tier structure, i.e. primary, secondary and tertiary levels. Traditional and allopathic medicine services are integrated and delivered under one roof. Village health workers play an important role as a bridge between health services and the community to promote health. Programmes are in place to address the public health challenges facing the country. Health services are free as enshrined in the Constitution of Bhutan. Therefore, government revenue is the predominant source of health financing.

Health services in the country are available through a three-tier structure: (i) basic health units (BHUs), sub-posts and outreach clinics (ORCs) at the primary level; (ii) district or general hospitals at the secondary level; and (iii) regional and national referral hospitals at the tertiary level. Comprehensive services are provided to citizens through various levels of care including treatment aboard, if a particular service is not available in the country.

The MoH is the central authority responsible for the development of health policy and for all other stewardship functions, as well as for organizing and provision of quality and comprehensive health-care services, including health promotion, disease prevention, curative and rehabilitative services. In line with the decentralization policy of the Royal Government of Bhutan (RGoB), health administration and management has been devolved to districts over the past few decades.

Despite the achievements, Bhutan is currently facing a multiple burden of health challenges. NCDs are increasing rapidly. Conditions such as hypertension, CVDs and diabetes are on the increase. The country has been successful in developing a good infrastructure for primary and secondary care levels and for public health services in general. But it is time to strengthen the tertiary care level and bring in a good balance of primary, secondary and tertiary care levels.

3.4??????? India:

Healthcare is one of India's largest service sectors. India is a union of 28 states and 9 union territories. States are largely independent in matters relating to the delivery of health care to the people. Each state has developed its own system of health care delivery, independent of the Central Government. The Central Government responsibility consists mainly of policy making, planning, guiding, assisting, evaluating and coordinating the work of the State Health Ministries. The health system in India has 3 main links Central, State and Local or peripheral. Health system at the national level under Ministry of Health and Family Welfare consist of three department; Department of Health and Family Welfare, The Directorate General of Health Services, and the Department of Health Research. There is one Central Council of Health (CCH) which is headed by Union Minister of Health and Family Welfare as Chairman and Health Ministers of all the States are its members. The purpose of CCH is to promote the coordination between the Centre and States in the implementation of national programmes and measures pertaining to health.

The health subjects are divided into three groups: federal, concurrent and state. The state list is the responsibility of the state, including provision of medical care, preventive health services within the state.

Structure and Organisation under the Constitution of India, health is a state subject. Each state therefore has its own healthcare delivery system in which both public and private (for profit as well as non profit) actors operate. While states are responsible for the functioning of their respective healthcare systems, certain responsibilities also fall on the federal (Central) government, namely aspects of policy-making, planning, guiding, assisting, evaluating and coordinating the work of various provincial health authorities and providing funding to implement national programmes.

The organisation at the national level consists of the Union Ministry of Health and Family Welfare (MoHFW). In each State, the organisation is under the State Department of Health and Family Welfare that is headed by a State Minister and with a Secretariat under the charge of the Secretary/Commissioner (Health and Family Welfare). The Indian systems of medicine consist of both Allopathy and AYUSH (Ayurveda, Yoga, Unani, Siddha and Homeopathy). The district level structure of health services is a middle level management organisation and it is a link between the State and regional structure on one side and the peripheral level structures such as Primary Healthcare (PHC) and Sub-Centre on the other.

India’s healthcare system is characterised by multiple systems of medicine, mixed ownership patterns and different kinds of delivery structures. Public sector ownership is divided between Central & State governments, municipals and Panchayats (local governments). The District Hospitals and Medical Colleges are at the tertiary level, the Community Health Centres (CHCs) and Sub-district Hospitals make up the secondary level, Primary Health Centres (PHC), Sub-Centres (Health & Wellness Centres- HWCs) and health posts are the Primary level of health care services. There are other public facilities for selected occupational groups like organised work force (Employees State Insurance Scheme), defence, government employees (Central Government Health Scheme – CGHS), railways, post and telegraph and mines among others. ?The providers of healthcare at these different levels include both public and private actors, but there is an increasing dependence on private providers.

There are many challenges in healthcare system in India, as

-????? Economic deprivation in a large segment of population results in poor access to health care.

-????? Lack of awareness towards health and sanitation. The gender inequality and explosive growth of population contribute to increasing burden of disease,

-?????? limited access to preventive and curative health services, and inadequate human resource for health,

-?????? Government expenditure on health must urgently be scaled up, from <2% currently to at least 5%–6% of the gross domestic product (GDP) in the short term. This is in contrast to the Out-of-Pocket Expenditure (OPE) which comes out to be 64.58 % of the total health expenditure (World Bank), and the catastrophic healthcare cost is an important cause of impoverishment.

-?????? Lack of accountability is also a major challenge in health care systems.

3.5?????? Maldives:

The health care delivery system of Maldives is organized into a four-tier system with island level primary health centres, a higher level of health facilities with respect to provision of maternal and new born care at an atoll level, specialty care hospitals at regions (groups of 2-4 atolls) and tertiary care at a central level. Health centres have four levels and health posts are also referred to level four health centres. Administratively, the regional or atoll hospital in each atoll acts as the main coordinating body in providing primary and curative health care in that atoll and each atoll covers a population of 5,000 to 15,000 people. Hence, to ensure access to health care, health facilities are established even if the population number is low.

Therefore, the distribution of PHC centres is island based and not population based resulting in inefficiencies in terms of material, human and financial resources. Health care services including medical examination, investigations, immunization, antenatal care, drugs etc. are provided free to all Maldivian citizens. However, the delivery of services at primary health centres at rural level is challenged due to the geographic isolation of islands and inadequate human resources, specialties, supplies and equipment and poor management.

The private sector in health in the Maldives, although small, is vigorous and distributed widely across the islands. According to the register of all clinics maintained by the Ministry of Health, there are 65 private health care facilities of which most (73%) are located in Male’. The Health Master Plan (HMP) 2016-2025 represents a strategic framework for the prioritization, implementation and monitoring of the health services and programmes, as well as a guide for development of a comprehensive business plan for all partners in health in Maldives.

3.6????? Nepal:

Nepal has undergone substantial political changes over the last three decades. Responding to the aspirations of the Nepali people, on 17 September 2015, the second Constituent Assembly ratified a new Constitution, transforming the country from unitary state into a Federal Democratic Republic. The new Constitution institutionalizes inclusive and participatory democracy with specific civil and human rights, including the right to a clean environment (Article 30) and the right to health as specified in Article 35, additionally, Article 38 recognizes women’s rights to reproductive health and safe delivery services.

Ministry of Health and Population (MoHP) consists of 3 departments: Department of Health Services (DoHS), Department of Ayurveda (DoA), Department of Drug Administration (DDA). There are 5 Regional Health Directorates (RHDs) functioning directly under MoHP. There are 61 districts are managed by District Health Office (DHO) with support of District Public Health Officer (DPHO), whereas the remaining 14 districts are managed by DPHO solely. There are some regulatory bodies like Nepal Medical Council (NMC), Nursing council, etc. The responsibility to deliver “basic” health services is the sole responsibility of local governments, while the federal government largely have its responsibilities to policy-making, regulations, standards development and monitoring.

The challenges before Nepal’s health care system are; Climate change and health, ??Equity, accessibility, quality and coverage of essential health care services, Nutrition, Inter agency coordination, Sustainability of health programme, new emerging diseases, Deployment and retention of Human Resources for Health(HRH) in remote and rural areas and Increase in non-communicable diseases.

3.7???? Pakistan:

Pakistan has a mixed health system that includes public, parastatal, private, civil society, philanthropic contributors, and donor agencies. In Pakistan, health care delivery to the consumers is systematized through four modes of preventive, promotive, curative, and rehabilitative services. The government of Pakistan spends about 2.75 % on health care, which is higher than Bangladesh (2.37 %) and lower than India (3.66 %) & Sri Lanka (3.89 %).??

The healthcare delivery system of Pakistan is complex because it includes healthcare subsystems by federal governments and provincial governments competing with formal and informal private sector healthcare systems. The Ministry of National Regulations and Services was re-established in April 2012, reinstating a federal body to provide health services and implement healthcare policies. The public health sector consists of 10,000 health facilities with both Basic Health Units (BHUs) which cover around 10,000 people and Rural Health Centres (RHCs) which cover around 30,000 to 45,000 people.

Public healthcare institutions that address critical health issues are often only located in major towns and cities. Due to the absence of these institutions and the cost associated with transportation, impoverished people living in rural and remote areas tend to consult private doctors. Studies have shown that Pakistan's private sector healthcare system is outperforming the public sector healthcare system in terms of service quality and patient satisfaction, with 70% of the population being served by the private health sector. In? the? public? sector,? under? the? Devolution? Plan? of? the Government of Pakistan, the districts have been given comprehensive? administrative? as? well? as? financial autonomy? in? almost? all? sectors,? including? health.? The districts are now responsible for developing their own strategies, programs and interventions based on their locally generated data and needs identified.

The nationwide network of medical services consists of 796 hospitals, 482 RHCs, 4616 BHUs and 4144 dispensaries, only 25 per cent of the BHUs and RHCs have qualified female health providers.

Healthcare system of Pakistan especially primary Healthcare is facing numerous problems. Decentralization presents an opportunity to bring in fundamental changes in Primary Healthcare to make it more efficient and effective to the masses. A goal of reforms in Primary Healthcare sector is to restructure the non-efficient system by devolving from Federal to district level.

3.8????? Sri Lanka:

Sri Lanka holds a unique position in South Asia as one of the first of the less developed nations to provide universal health, free education, strong gender equality, and better opportunity to social mobility. The health system in Sri Lanka is enriched by a mix of Allopathic, Ayurvedic, Unani and several other systems of medicine that exists together. As in many other countries Sri Lankan health system consists of both the state and the private sector.

The Ministry of Health is the centralised apex body under the GoSL and will carry forward the objectives as listed in the health master plan. The MoH is responsible for the provision of comprehensive health services which include services for preventive, curative and rehabilitative care. The MoH is headed by the Minister of Health and Deputy Minister of Health followed by Director of Health Services. The Director General (DG) of Health Services is the officer responsible for providing guidance to policy makers at a political level, policy making, programme planning, and implementation for all health services in the country.

Public healthcare is provided through three tiers, and is organised as primary, secondary and tertiary level hospitals on the basis of size and facilities offered. Facilities that offer non specialist inpatient and outpatient care such as maternity homes, central dispensaries, rural hospitals, peripheral units and divisional hospitals are categorised as primary level hospitals. Secondary care institutions include base hospitals, district general hospitals and provincial hospitals. According to the Ministry of Health, utilisation of inpatient healthcare services is dominated by the public sector, whilst outpatient care is dominated by the private sector.

4.??? Challenges Ahead:

Sixth Meeting of the SAARC Health Ministers was held at Colombo, on 29 July 2017. The Health Ministers adopted the Colombo Declaration “Calling for accelerated progress on key Regional Health Issues”, in which the Member States noted the ten Key Messages/Recommendations of SAARC-UNICEF Regional Conference on Scaling-up Care for Children with Severe Wasting in South Asia (Kathmandu, 16-18 May 2017); significant economic contribution made by labour migrants of the region and agreed to collaborate to safeguard their health; conducting annual meetings on Non-communicable diseases by rotation in each Member State; and agreed to conduct activities as individual Member States and also as a Region according to the principles and strategies agreed upon in the two South Asia Regional Action Frameworks on Sanitation and Nutrition to improve the status of sanitation; establish mechanisms to share the experiences on development of human resources for health, ensuring the accessibility, equity and quality of health care in each country and as a region; share experiences on best practices adopted on health issues pertaining to Non-Communicable Diseases, Vector Borne Disease, Sanitation, Nutrition, Climate change and Disaster; work together to achieve the Sustainable Development Goals through enhanced partnership and collaboration. The Secretary General of SAARC offered about establishment of South Asian Medical University. The Meeting also welcomed the offer of Sri Lanka to host the University.

5.???? Conclusion:

SAARC member countries need a holistic approach to tackle problems in healthcare industry & its administrative setup. This includes the active collaboration of all stakeholders public, private sectors, and individuals. Changing disease patterns from communicable to non-communicable diseases is being witnessed and it expected to only rise in future. Hence a more dynamic and pro-active approach is needed to handle the dual disease burden. Cooperation among Central and State governments is to be promoted in policy making and exploring options like UHC to cater to the health of the population and eliminating the malpractices that exist in the system with effective policy implementation.

Financial support and sponsorship:

Nil.

Conflicts of interest:

There are no conflicts of interest.

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