Exploration of Pneumonia Related Policy Formation and Implementation in Pakistan

Despite the availability of standard pneumonia management guidelines and multiple global efforts, pneumonia continues to be the leading killer of children under five, accounting to around 17% of the total under five deaths globally. It has been estimated that annually there are around 120 million episodes of pneumonia among children with around 14 million progressing to severe episodes. Out of these cases, close to 1.3 million children die with 81% of these deaths occurring under 2 years of age. 52% of these deaths occur in the Sub-Saharan region and South Asia with main contributions from India, Nigeria, Congo, Pakistan and Afghanistan. In Pakistan, pneumonia contributes to 16% of under-five mortality in the country with annually around 65,000 children dying due to this disease; a status unchanged for more than a decade.

In order to reduce pneumonia related morbidity and mortality, World Health Organization (WHO) and United Nations International Children's Emergency Fund (UNICEF) have developed multiple action/ intervention plans. This includes initiatives like the Integrated Global Action Plan for the Prevention and Control of Pneumonia and Diarrhea, Global Strategy for Women's and Children's Health, Committing to Child Survival, Global Vaccine Action Plan etc. All these initiatives/interventions focus on a unified goal of "ending preventable deaths". They bring together critical interventions to promote practices to save lives of children, to create healthy environments and to have access to appropriate preventive and treatment measures. Pakistan, among other countries, has been actively involved in various related forums on prevention and management of pneumonia. But for best outcomes at national level, such initiatives need to be supported by appropriate policies/strategies because policies entail political and strategic support for best management and care. Also needed is engagement by regional governance structures, including roles such as coordination, funding, and guidelines for policy development.

Pakistan has launched multiple national programs in line with these global initiatives at various periods of time. These programs include the National Acute Respiratory Illness (ARI) control program which was launched in 1989 with the main objectives of reducing severity and mortality due to pneumonia and rationalize the use of antimicrobial and other drugs for treatment of ARI. WHO soon realized that this disease centric narrow approach has not been able to achieve its desired objectives. Therefore, it developed a more integrated approach and launched it globally as Integrated Management of Childhood Illnesses (IMCI) launched in Pakistan in 1998. The approach in IMCI focused on improving case management skills of health workers, strengthening the health system, and addressing family and community practices. Duplicity was very much evident from the fact that ARI existed as an independent program and was also part of the IMCI package. Between 2004-2010 The Pakistan Initiative for Mothers and Newborns (PAIMAN), a United States Agency for International Development (USAID) funded project was undertaken which focused on improving the status of maternal and newborn health in 24 districts across the four provinces and Azad Jammu and Kashmir (AJK) in Pakistan. ARI was an important component in that project. Thereafter, a national Maternal, Neonatal and Child Health program (MNCH) was launched in 2010 funded mainly by Department for International Development (DFID) focused on strengthening of management and organization mechanism of healthcare delivery systems which ended after 5 years.

This shows that there has been a constant flow of ARI related program initiation and termination which could be attributed to the unsteady health policy environment of Pakistan markedly influenced by the unsteady political environment. Before 2011, the health ministry at the federal level was responsible for policy development, implementation, monitoring and surveillance. In June 2011 in wake of the 18th amendment of the national constitution, this National Health Ministry was devolved. This led to the shift of certain responsibilities from the federal level to the provinces. As a result, health policy formulation, planning along with service delivery was devolved to the provinces leading to differences in health outcomes across the country. Considering the development of all these programs/strategies/policies has been influenced by various stakeholders including the ministry, academicians, researchers, physicians, and development partners, it is, therefore, important to understand how different actors come together and influence policy making and implementation. This could assist in exploring the existing policy support for reducing pneumonia related morbidity and mortality and thus underpin recommendations for improving the status.

Primary Objective