The situation calls for an urgent shift from the traditional health development systems to innovative and modern health facilities. The following four seem to be the obvious factors responsible for the poor health standards.

(a) lowest government priority for health sector as indicated by 0.65 per cent of the budget allocation in 2008-2009 (b) high rate of poverty and low affordability (c) low health awareness among masses because of low literacy rate (d) absence of joint government and private participatory health facility system..

These identified areas need to be looked into and building upon the findings, a true participatory health sector development and management system can be developed with Public Community Partnership (PCP) approach.

The role of public sector organisations in the provision of health facilities is shrinking as 48 per cent of these operate on commercial basis. Of these, 80 per cent are concentrated in the urban areas with negligible state regulation. The third sector organisations such as government, NGOs; charity organisations and Citizen Community Board (CCBs) operate independently.

The isolated approach of dealing with the health challenges has not borne fruits in the last 60 plus years. The public community partnership (PCP) model of sustainable health system can be an effective approach to deal with the problems.

The rationale of this model is that the health development programmes cannot operate in isolation as it is one of the national development indicators which are an outcome of interplay of the other social sectors. The ills of this sector can be identified in the ongoing vicious cycle which starts with the low literacy rate (health awareness), poverty trap, and their indifferent attitude towards health which finally ends up as ineffective health programmes/projects. The integration of the other development functional areas with the health focused organisations/systems through PCP approach could be an effective solution to the challenges of deteriorating health systems.

The PCP model exists as a provision of CCB in the Local Government Ordinance (2001). In this approach, local people form CCB according to the local priorities with their 20 per cent financial contribution and 80 per cent coming from the local government's development budget.

Till the end of 2007, 149,003 CCBs have been registered by the local governments. The exact figure of the active CCBs, till the writing of this article, are not known but a handsome amount of Rs3748 million was disbursed to many active CCBs till 2008.

Though the political will towards strengthening devolution and local government system is on the decline since the new government assumed power after February 2008 elections, the effectiveness of CCBs cannot be denied or ignored.

Apart from the politics of 'power' and 'privileges', the institution of CCBs should be utilised to extend the outreach of local government in developing grass-root health systems along with education, income generation and general awareness of community living.

The success stories of CCBs from Khairpur and Peshawar rural districts are inspiring, though these are the outcomes of individual efforts and not an outcome of the system.

In order to develop a participatory health system in less developed areas, there is a need to expedite the formation of health, education, general awareness, and income generation focused CCBs by the local people under the guidance of the local and provincial government departments.

The CCBs alone have been found largely less effective due to their capacity gaps. The concerned government departments should join hands with the communities and provide technical support in developing CCBs without imposing their will. Some obvious areas of support and cooperation can be through project proposal writing, financial/organisational management, maintaining quality standards by establishing networking with other government's departments responsible for social development.

A prospective model for participatory health development mechanism has been conceptualised as in the figure.

This model suggests a strong network of the local government departments that provide guidance and support to the community to establish CCBs in line of their functional areas. Once, the appropriate numbers of CCBs are established they develop a network of support and cooperation with other thematic CCBs for mutual cooperation for an integrated social development.

Since the point of discussion is health improvement, health-related CCBs have been placed in the centre. This model can also provide guidance for the development of the other sectors by replacing the health focused CCBs by the other thematic CCBs.

The participatory health system development is needed by the resource constrained countries like Pakistan. Building upon the last five years' experience of the CCBs, a minor modification in the institutional arrangement of the local government will unleash the potential it has for the local development in all walks of life. Health systems development is no exception.