Developing a health manifesto is a meticulous task and requires a thorough understanding of the public health challenges the country faces. It must follow a systemic approach to understanding the political system and consulting experts for effective evidence-based policy recommendations and commitments.

Pakistan continues to face critical health workforce shortage and serious governance challenges in face of the 18^th Amendment that made fundamental changes to both the federal & provincial health mandates. Pakistan’s Universal Health Coverage index stands at a dismal 40, second lowest in South Asia after Afghanistan.

The country shares 3 per cent of the global maternal death burden, the highest rate of risk of neonatal deaths on day of birth globally and the slowest progress in reducing newborn deaths. 50% die of non-communicable diseases and an equal burden is shared by infectious diseases.

Input of technocrats or available evidence is seldom used to derive or rationalise policy and programmatic interventions. Crippling gaps exist in laws and regulation of health workforce in both public and private sector. Still, impoverishment and inequitable distribution in health system continue to be the key impediment to quality health for the people of Pakistan.

The 2013 manifestos of all the five leading parties showed a considerable overlap, highlighting the prioritisation of health-related global targets, with focus on improved health spending, maternal and child health indicators, immunisation coverage, strengthening of service delivery and introducing health insurance programmes. None of the 2013 manifestos considered public health a priority.

The 2017 provincial health surveys in Punjab and KP confirm improvements in immunisation coverage and other key maternal and neonatal health indicators, whereby Punjab is only 2 per cent behind the World Immunisation coverage of 86 per cent. In comparison, although KP made a slower progress on the health indicators as per UNDP and Health Survey II report, it is still ahead of Sindh, Balochistan, AJK and Gilgit Baltistan, where situation remains dismal.

The proposed recommendations for the health manifesto 2018-2023 are a compilation of policy recommendations received at the recently organised policy roundtable series by the Punjab Public Health Agency attended by national and international public health experts. It considers an end-of-five-years health sector assessment and the evidence base generated by the recent third-party surveys that underpin the health sector performance measurement framework. These technical recommendations encompass the entire spectrum of the continuum of care and ensure a close focus on pro-poor and equity promoting interventions. They are valuable for the competing political parties as they put their health manifestos together.

Health needs to be positioned in all policy frameworks as the cornerstone of sustainable development. The agenda calls for enhancement in the overall spending on health to 4-5% of GDP as recommended by WHO, strengthening of health systems, and restructuring role of the health licensing and regulatory bodies.

There is a need to regulate forensic examination and a system to test fertilizer, pesticide, food and drugs to ensure quality. Globally there is an immense emphasis on achievement of universal health coverage. We can build upon the lessons learnt from the health insurance programme rolled out in KP and Punjab that introduced pro-poor healthcare intervention. Focus must be kept on strengthening of preventive and promotive healthcare which has been sidelined for long.

It is critical to integrate family planning within the healthcare service delivery system in order to reduce population growth rate to minimum of 1.6. There has been success in improving immunisation coverage but this must be sustained. For compliance with the International Health Regulations, effective infrastructure for integrated disease surveillance and response need to be established.

Realising that 50% of deaths are due to non-communicable diseases including cancers, there is an immense need to launch dedicated programmes for their prevention, early detection and timely treatment.

The current number of LHWs must be enhanced to meet the need of the uncovered areas. Rural ambulance networks can help improve access to quality care of marginalised communities. Malnutrition must stay as a priority agenda for the next five years with introduction of nutrition interventions during the ‘first 1000 days’, for reducing neonatal and infant mortality. Scope of services and diagnostics at the tehsil and district level hospitals must be enhanced for meeting the population health needs. Engaging general practitioners in the service delivery network is expected to optimize the current health service delivery system.

It is important to align the supply of specialized healthcare services to the disease patterns. Nationwide network of blood centers needs to be ensured. For organ transplants, a regulatory framework can be considered. Public-private partnerships for setting up new hospitals in socio-economically deprived areas should be a sought-out strategy. Disability must be prevented as well as reduced. Programs should be introduced for supporting disabled community and senior citizens.

Health workforce shortage remains a critical challenge. For an optimal skill mix the production of allied health professionals and nurses must be increased.  The number of health human resource employed in public sector also needs to be enhanced. Demand driven investments in medical education, introduction of Hospital Management Cadre, development of a critical mass of public health professionals and establishment of a nursing and public health university in the country are all highly needed initiatives.

There is a rich body of evidence available, albeit provincial. There are substantial lessons to be shared internally, and successful experiences to be replicated. It is pertinent that the parties engage technical experts to ensure that their manifestos are built upon the available evidence, and commit to equitable health reforms across the country.

The writer is a senior public health

expert with extensive national and

international experience.