ASSESSMENT OF KHYBER PAKHTUNKHWA HEALTH POLICY IN THE CONTEXT OF SDG 3

This comprehensive study delves into the Health Policy of the Government of Khyber Pakhtunkhwa (KPK), evaluating its alignment with the United Nations Sustainable Development Goals (SDGs) to provide inclusive and sustainable healthcare practices to the citizens of KPK. This research focuses on critical dimensions such as mortality rates, new hospitals, disaster management, health insurance, and accountability mechanisms. The research shows little improvement in neonatal and child mortality rates requiring interventions and maternal health initiatives in the shape of adequate healthcare infrastructure in various regions of the province. Moreover, the scarcity of paramedical staff and beds requires the expansion of infrastructure and strengthening of the workforce. This paper advocates several recommendations to address shortcomings and pave the path for sustainable development, including the extension of health insurance facilities to rural areas, creating a power accountability mechanism for efficient service delivery, and providing comprehensive disaster management training. Moreover, promoting “MADE IN PAKISTAN” products in the medical equipment field and using digital health technology is a key recommendation for this research to improve health accessibility. The integration of SDGs into the policymaking process can advance the KPK Government in healthcare services, leaving no one behind. This research contributes to the broader global efforts toward sustainable development, fostering a healthier and more prosperous future for the people of Khyber Pakhtunkhwa.


INTRODUCTION
The World Health Organization defines all activities that promote, restore, or maintain health as a health policy (WHO, 2000).According to the United Nations Sustainable Development Goals 2030, health has been marked as a specialized sector to ensure healthy lives and promote well-being, irrespective of age, gender, or race (UN, 2015).Pakistan is a lower middle-income country having an agrarian economy (UNICEF, 2022).
Different researchers in the past have defined policy as not a document that contains things said by people or the government but contains what has been done (Bjorkman, 1986).A policy has two different parts: the first checks and evaluates the desired goals for the future, and the second consists of the empirical part of a policy containing records and practices observed in the present era.To achieve these objectives, a clear-cut health strategy can be helpful, as it presents a healthful picture of a country's future.It also creates and draws the role of a diverse cluster along with significance and dominance, making it possible for the country to transform the masses and achieve treaties and harmony (Asim, 2019).There is extensive literature on health reforms in Pakistan; however, no specific work has been done on the current problem, making the researchers work on a specific area through this work.
Pakistan first presented its health policy in 2001, which was later redrafted and presented as the National Health Policy 2009.After the enactment of the 18 th Amendment, the subject of public health shifted to the provinces.The Federal Ministry of Health was dissolved in 2011; however, due to the lack of a federal Ministry, several issues evolved that forced the re-establishment of the Ministry of Health Services in 2013.
At the same time, the Government of Pakistan introduced the National Health Vision 2016-2025 (MOH, 2016).This policy is aligned with Vision 2025, health priorities set by International Organizations, and realities faced by provinces.However, this Vision does not depict loopholes in health policies, as it defines overall guidelines to confront health challenges, keeping in view Universal Health Coverage as the final goal.According to the National Health Vision, the provision of healthcare services has been entrusted to provinces; however, priority actions as per the vision of the Federal Government have been made in concert with provincial expectations, needs, and priorities.This policy was developed to facilitate provinces in the development and implementation of strategies to ensure the accessibility of essential health services to all citizens of Pakistan.To scrutinize the basic health services, this assignment aims to review the Government of Khyber Pakhtunkhwa's health policy to provide them with a document to review gaps in the policy.

METHODOLOGY
Although very little attention is given to the comparative analysis of policies focusing on evaluating factors (Marta Foresti, 2007).To evaluate the similarities and differences in policies and administration, a comparative analysis is key to apply for compare social and economic context, social change, and the role of institutions (Richard I, et al, 1998).This study uses a comparative research design by extensively reviewing the literature and comparing the proposed policy and on-ground realities after the passage of a sufficient amount of time of implementation of the policy.

KPK Health Policy 2018
The KPK is the northwestern area of Pakistan, with seven divisions and 36 districts.As per the population census 2017, it has a population of 30.5 million and the growth rate is 2.89% compared to the previously held official census in 1998 (PBS, 2022).Most of the population resides in rural areas.
The government of Khyber Pakhtunkhwa's current health policy was designed in 2018 after considering the issues, needs, and challenges related to healthcare services in Khyber Pakhtunkhwa province.The Principles of this Policy are ensuring universal health coverage for all with Equitable, Universal, Accountable, Community oversight, Results based management, & and involvement, Quality of care, Community focused, Safety for patients and staff, Innovative Responsive, Transparent, and Sound management & and governance The policy aims to provide essential health services to vulnerable and poor communities.The policy also aims to reduce the burden of the disease, especially among vulnerable groups.This policy has also set goals to improve governance, human resource management, accountability, and regulation.The policy also aims to provide efficient service delivery with protection from financial risk.
Against the backdrop of this policy and the recommendations of the WHO, the Government of Khyber Pakhtunkhwa was the first to introduce the "Sehat Sahulat Card" for its citizens (Hassan, 2022).The citizens of KPK have been blessed with leadership in the health sector, who have materialized their agenda for change and formed a consensus-oriented and inclusive structure of governance with the introduction of this program (Zareef, 2017).The Sehat Sahulat Program in KPK stands as the pioneering micro-health insurance initiative, proving its success since its inception (Said, 2020).Although the program does not cover all diseases, it will be beneficial if it accommodates more healthcare fields (Rahman et al.

FINDINGS AND DISCUSSION
Although a policy's success is measured by the satisfaction of the public, it can be more effective if a mechanism for reducing loopholes is developed.In Pakistan, very few organizations (the public sector) monitor and evaluate policies.In the policy-making process, monitoring, and evaluation of a policy have a key role in the enhancement of a policy.After thoroughly reviewing the health policy, the following critical points have been identified, which require the attention of the KPK Government to provide a fruitful outcome to the citizens of KPK.
Low Improvement in Neonatal, Infant, and Under-5 Mortality Rate Neonatal and infant mortality rates are the most important indices that indicate the level of public health in a country (Chang et al., 2011).The KPK Health Policy focuses on reducing neonatal, infant, and under-5year age children's mortality rates.The figures show the comparison of neonatal, infant, and under-5 mortality rate of Punjab, Sindh, and KPK compared for the year 2013 and 2018.Accordingly, the United Nations Population Fund (UNFPA) reported that the neonatal mortality rate was 41 in 2013; however, no improvement was shown in 2018, and it has increased to 42 (UNPF, 2020).As per the report of the UNPF, the infant mortality rate in KP was 58 in 2013, which was reduced to 53, and it is the lowest among all provinces.On the other hand, the under-5-year mortality rate was 70 in 2013 in KP; however, this dropped to 64 in 2018, which is also the lowest among the provinces.

Availability of Beds and Paramedical Staff
Life expectancy has increased worldwide due to diverging improvements in the field of medical science.Thus, demanding increased and effective services leads to rising costs and workforce survival to meet the needs of the patients (Dicuonzo et al. 2020).As per the Asian Development Bank's report, 0.5 nurses and other paramedical staff are available to 1000 persons in KPK.This ratio is comparatively lower than the overall average of 0.7 for Pakistan.
As per the Asian Development Bank (ADB), the following statistics are available for comparison of facilities in Lower Middle Income Countries (LMIC) and countries that are members of the Organization of Economic cooperation and Development (OECD).This policy goal has been a key priority that has not yet been fulfilled.The analysis was made using the location of hospitals and data available with district administration regarding the locality either falling in urban or rural areas.From the above analysis, it has been found that all hospitals in five districts are in urban / city areas making it difficult for netizens of rural areas to utilize the Sehat Insaf card facility.

Accountability Mechanism
Accountability has been found a key problem in the healthcare system (Emanuel E. 1996).Debates regarding quality improvement, cost control, and safety care raise the issue of accountability (Denis 2014).According to the Health Policy of the KPK Government, an accountability mechanism in the form of an Independent Monitoring Unit (IMU) is set to be enhanced.This policy point has been implemented but a more thorough examination is required, as the IMU is mandated to report on service delivery, staff performance, availability of free medicines and equipment, and utilities.However, no mechanism to review the performance of doctors and other paramedical staff has been provided to give performance-based incentives and to provide service delivery at an optimal level.

Lack Of Disaster Management Training
Disaster management during a disaster aims to avoid losses from hazards by providing effective and early assistance and achieving a prompt recovery.Health facilities deserve special measures allowing those to work on the already admitted patients and provide additional services to disaster-hit persons (Salamati Nia et al., 2017).Pakistan has been highlighted among the top ten vulnerable countries to disasters and climate change for the last two decades.However, disaster resilience building has been hindered due to the unavailability of administrative scale assessment (Sajjad M, 2023).Khyber Pakhtunkhwa is lying in a highrisk area for natural disasters and the study of history speaks louder about disasters faced due to natural emergencies.Policy documents have elaborated that RESCUE-1122 will be engaged in these kinds of services, but the KPK Government has not provided any mechanism for training on disaster management, liaison with allied departments dealing with disaster management, etc.

No policy for "Make in Pakistan"
In India's Health Policy, a special goal has been set to attract local businessmen to provide health devices and other technological instruments to be made in India.According to India Biotechnology and Bioinformatics, approximately 2,500 businesses are working in India in the field of biotechnology, employing 1 million people per year (Sindhu, 2023).Our National and provincial policies are silent on this factor, and our imports of medical equipment are growing at a large scale.Pakistan's medical equipment exports in 2021 were $ 480 million (SBP, 2022).All these stats require consideration as if the medical equipment industry is revolutionized, which will make our economy flourish as well.
No, Tend Toward Digital Health Facilities (E-Doctor Etc) Owing to the increase in digital health innovations, dramatic changes have been witnessed in the healthcare sector ( Kulkarni et al. 2023).According to the Internet Society of China, online healthcare services are being used by 215 million people by 2020 which makes up about 22 percent of the internet users across the world (CNNIC, 2021).The e-health facilities lead to cost reduction, better privacy, and less embarrassment with huge time savings (Cao X et al. 2017).In developed countries, the policy is in the implementation phase regarding "health facilities at home".However, the KPK Health Policy lacks this proactive approach, which requires a revisiting policy at this point only.

CONCLUSION
To conclude, this study has critically assessed the Health Policy of the KPK Government through the lens of UN SDGs.The analysis highlights challenges faced in various fields including child and neonatal mortality rates, infrastructure supporting the healthcare system, workforce capacity, digital health integration, and disaster preparedness.Through the analysis of available literature and data, we are drawing an opinion that the Government of Khyber Pakhtunkhwa's Health Policy 2018, if implemented, can be fruitful for citizens, as well as the Government.As per the analysis of policy, a few loopholes have been found in the health policy, and upon acting on these loopholes, this policy will meet the criterion of WHO and the Astana Declaration.Although policymaking is an intensive process requiring a long time to be designed, if implemented as per the soul of the policy, the discrimination against the poor class in health facilities will be eliminated which will reduce pressure on hospitals.The Government should make a policy to introduce Disaster Management in the health policy and more importantly, the trend toward Make in Pakistan may be given more importance to cut import bills as well as giving our economy a breath-taking movement by providing made-in-Pakistan health equipment.There should be a specific policy for allocating a budget for building at least one hospital in each division during each financial year which will reduce pressure on already available hospitals in the province.
The finding further indicates that transformative change and steering the province toward sustainable development requires expansion of healthcare facilities in rural areas, strengthening of the accountability process, and initiating domestic production of equipment.

RECOMMENDATION
This study reveals that several challenges are hindering the delivery of healthcare services.This study recommends the following to make health policy in line with International standards and SDG-3.
• To Develop targets addressing high neonatal mortality rates by emphasizing maternal health and providing proper access to maternal health services.• Special priorities may be given to the establishment of new hospitals especially in rural areas to increase accessibility and improve health infrastructure.• The shortage of paramedical staff may be addressed to meet international standards and impart professional training programs for quality services.• Sehat Insaf Card facilities may be extended to rural areas to provide equitable access to all citizens irrespective of geographical location.• Strengthen the IMU for comprehensive evaluation of healthcare service delivery, availability of resources, and staff performance.Provide a mechanism to initiate performance-based incentives for healthcare providers.
• Special measures be taken at the National level to promote "Make in Pakistan" and encourage local production of medical equipment making economic growth as well as job creation.

Table 1 :
Comparison of KPK with LMI and OECD Countries regarding Health Facilities ** Dissemination Of Health Insurance Facilities KPK Government is the first to introduce a health insurance policy in the shape of the Sehat Insaf Card which has brought a greater change in the health sector of Khyber Pakhtunkhwa.The policy includes the use of health insurance facilities (Sehat Insaf Card) and public-private partnerships have been utilized.