Expenditure tracking and review of reproductive maternal, newborn and child health policy in Pakistan.

Since 2001 substantial resources have been allocated to the reproductive, maternal, newborn and child health sector (RMNCH) in Pakistan. Many new programmes have been started and coverage of some existing programmes has been extended to un-served and rural areas. Despite these efforts the Millennium Development Goals (MDGs) 4 and 5 were not achieved (2000-15). Maternal Mortality Ratio was reduced to 170 per 100 000 live births (target 100) by 2013 at an annual reduction rate of 3.6% (1990-2013). Against the target of 46 per 1000 live births, the Under Five Mortality Rate was reduced to 81 per 1000 live births by 2015 at an annual reduction rate of 2.1% (1990-2015). We evaluated the comparative expenditures for the RMNCH sector and analysed impact of public expenditures on the use of the public facilities for the RMNCH services. Expenditure on RMNCH increased by 181% (2000-10), reaching PKR 628.79 billion (US$9.67 billion). The Share of the RMNCH expenditure in the total health expenditure increased from 16 to 21% (2005-10). The share of official development assistance for the RMNCH increased from 36 to 51% (2003-10). Equity was modestly achieved with a greater proportion of the poor using public facilities for the childhood diarrhoea (Concentration Index -0.06 in 2001-02 to - 0.11 in 2010-11) and reduction in the proportion of the rich using the public health facilities for institutional births (Concentration Index 0.30 in 2001-02 to 0.25 in 2010-11). Overall the RMNCH disease control programmes focused on vertical primary health approach and targeted the district health system in the un-served areas. Our findings confirm that diseconomies of scale, donor dependence and supply side perspective could only result in a modest progress towards achieving the MDGs. We call for urgent attention of the policy makers for the integration of the vertical and the routine primary health care and reliance on indigenous sustainable healthcare financing. We also recommend acknowledging economic perspective on health policy and health programmes.