HEALTH SECTOR & CRITICAL CHALLENGES AHEAD

FOZIA ISHAQUE (fozia.ishaque@hotmail.com
Sep 24 - 30, 2007

DISMAL HEALTH CONDITIONS IN PAKISTAN:

The health status of Pakistan is characterized by a high population growth rate, high incidence of low birth-weight babies and maternal mortality. The severity of health poverty is closely reflected in the country's poor health indicators. Infant mortality rate is 70 per thousand live births; life expectancy is 62 years. Although country's health indicators improved over time but its pace has been slowed. Maternal mortality rate is also high at 435 per hundred thousands births, largely because above 75 percent of births take place at home, under the care of traditional birth attendants. The proportion of low birth weight babies is also high; and proportion of under 5 malnourished children is 101 per thousand, about 10 million children under five years are malnourished resulting in 61 percent being stunted, 39 percent being under weight and a certain percent being wasted. The country's health indicators depict a dismal picture when compared with other countries at the same level of development. The country's health indicators are poorer than the low-income countries such as India, Bangladesh, China and Sri Lanka.

During the last three years, the public sector expenditure on health has increased by 11.7 per cent per annum. Currently it works out to be 0.57 percent of the GDP against eight per cent average of OECD countries with 14 percent of GDP spent on health by the US. In many developing countries the health spending ratio stands at 5 percent of the GDP. The current progress report on millennium development goals indicates that at the current pace of progress the country would miss most health related targets.

Due to poor economic conditions and lack of attention by the authorities infectious and fatal diseases are rampant throughout the country. Malaria exists in parts of Pakistan year round. Dengue fever is another reason to protect against mosquito bites. Typhoid, Hepatitis A, Japanese encephalitis and polio are also a risk. Bird flu has been confirmed on poultry farms and found in wild birds, and thousands of birds have been culled, but no human infections have been reported. There is a risk of diarrhoeal diseases; cholera and Hepatitis E. Outside the major cities there are few hospitals of a high standard. Besides these issues people hardly have access to healthcare services.

WHO Constitution, in 1948, defined health as "a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity. Later on, the World Health Assembly recognized that the spiritual dimension must also be included in country's strategies towards achieving the goal of Health For All (HFA). Health in the modern era is both a sensitive as well as a complex issue. Once only in the hands of physicians, healthcare now involves the crucial role of socio-economic agencies and political setups. It should be understood that the health of a nation depends not simply on the provision of doctors, hospitals and sophisticated equipment. It depends on the existence of basic health concepts, not only in the minds of individuals but also in the mind of those who frame policies and enjoy the power of implementation.

MISERABLE OUTLOOK OF HEALTH UNDERLYING CAUSES:

The health care system in Pakistan is plagued with numerous problems which are caused by factors like scarcity of resources, inefficiency and lack of functional specificity and accessibility and structural fragmentations etc. While probing into the matter we come across the below mentioned reasons which are undermining the whole system:

1-LOW SPENDING IN HEALTH SECTOR: The poor outcome in health can mainly be attributed to allocation of insufficient resources and lack of interest by government authorities. As a matter of fact our country is faced with a precarious economic situation characterized by heavy external debt and faltering productivity in all sectors. These issues are predominant and hence there prevail limited concerns to maneuver with health sector reforms. The portion of budget for healthcare is very low relative to other developing countries. In addition, even this low level of spending on health sector lowered from 0.58 percent of GDP in FY99 to 0.57 percent of GDP in FY07. However according to Federal Minister for Health, condition of health was deteriorating earlier when the health budget of the country was merely Rs.3.4 billion which was substantially enhanced up to Rs. 50 billion. The health budget for provinces has also recorded manifold annual incremental hike (not as a percentage of GDP) but is still inadequate to meet the needs of masses.

2-ACCESS TO HEALTH SERVICES: Access to health services is estimated to be available only to 55 percentage of the population, which is further decreased to 30 percentage overall for maternal and child health. About 57 percent of children complete routine immunization and only 40 percent of pregnant mothers are fully vaccinated against tetanus, for example. Health services are likely to be further challenged due to the demographic pattern of the population, with 43 percent younger than 15 and nearly 46 percent of females in the reproductive age (15-49).

3-INEFFECTIVE DELIVERY OF SERVICES: The provision of primary healthcare services and availability of a sound infrastructure in this regard is never ensued in rural areas in particular. There is always dearth of appropriate consultants, paramedical staff and life saviors. Basic health units (BHU) are established in rural and urban sectors but they fail to provide adequate service when required. Although doctors are appointed on contract at a reasonable salary but they avoid to work in BHUs as they have no incentive to work in rural areas at such a low remuneration. Similarly, health personnel get paid their salaries but absenteeism is uncontrolled. This reflects collusion between the health personnel and the district health offices at the expense of the poor. There is deficiency of an integrated and essential services package at different levels of health care delivery system covering preventive and curative services.

4-IMPROPRER UTILIZATION OF FUNDS: Not only the spending on health sector is low but also its allocation within the sector is directed to the areas that do not benefit the poor. Clearly, high priority is given to hospitals, medical colleges and curative services in urban areas, while primary healthcare and rural health service have been ignored which has led to a high rural-urban disparity in health care resulting in rapidly increasing poverty level in rural areas during the last decade.

5-POVERTY: Pakistan bears a high burden of poverty-related communicable diseases, exacerbated by malnutrition and maternal risks. Poverty is thus both a consequence and a cause of ill health. Miserable health compels people into poverty through lost wages, high spending for acute illnesses and repeated treatment for other illnesses. Due to inadequate nutrition and hence lowered immunity, poor are more susceptible to disease throwing them deeper into poverty. A recent health survey shows that 55 percent of the poor and 65 percent of the extremely poor are ill in Pakistan. The poor quality of most government medical facilities and the lack of access by the poor forced them to go to private medical practitioners or quacks. Of the poor, very few go to private medical practitioners, majority to government hospitals, some to government dispensaries and a little percentage to homeopaths, hakims and others. Ironically, a large number of private allopathic medical practitioners are poorly trained and have inadequate diagnostic facilities. As a result, the poor suffer a protracted illness and get locked into a high cost source of medical treatment. Since wages are commonly low, particularly in rural areas, unskilled labor, subsistence farmers and small holders are often forced to sell their meager assets and eventually borrow money to finance the treatment of the loved ones. Thus, the prevailing primary healthcare system in Pakistan pushes a vulnerable household into poverty and the poor households deeper into poverty. This is one of the explanations of a rapid rise in rural poverty noted during the current times.

6-LACK OF RESOURCES: The major issue in primary healthcare system is the lack of capacity in district health offices in terms of human and financial resources that restrain their ability to provide primary and secondary health services to local population. Shortage of equipment and staff at Basic Health Units/Rural Health Centers, particularly lady doctors, nurses, lady health workers, laboratory equipment, and drugs continue to affect the health system badly. The BHUs are designed for primary healthcare in rural areas but most of them are non-functional because of absenteeism by doctors and health personnel.

7-CORRUPTION: The corruption and collusions between paramedical staff and district health offices is also reflected by the fact that government medicines are sold in private market while spurious medicines are supplied to the poor patients making their life more miserable. There might be several reasons. Briefly, the primary healthcare system has fallen a victim to corruption and political influences.

8-INCIDENCE OF NONCOMMUNICABLE DISEASES: Non-communicable diseases (NCD) and especially cardiovascular diseases (CVD) represent a major health burden in the industrialized countries and are becoming a rapidly growing problem in Pakistan. Factors such as unhealthy nutrition, smoking, physical inactivity, psychosocial stress and alcohol use are among the main contributors to the occurrence and spread of NCD.

SUGGESTIONS:

Attainment of the highest standard of health is a fundamental right of every human being. But it is simply embarrassing and perplexing that a country like ours, with reasonable resources and infrastructure has one of the poorest public health standards in the world. The medical profession, public, media and governmental agencies have to act in an integrated way to change this appalling situation. Government should take serious steps and the vision behind any propositions pronounced for betterment of health should be to reorganize the basic services for all within the existing resources through restructuring of infrastructure. Government of Pakistan (GOP) should delineate a mission to serve the poor to improve their health conditions by streamlining the primary healthcare services that save them from private practitioners and quacks. The objective should be to let the poor know that the state lives and cares for them. Community mobilization and health education should be an integral component of this restructuring. GOP should devise an institutional mechanism in the health sector to establish a prompt effective emergency and disaster response system whenever required.

For rapid improvement and revitalization of the sector government should take following steps immediately:

* The responsibilities of public health are to be handed over to the district Governments, with appropriate funding and tax generating powers. The provincial governments should act as monitoring and regulatory authorities.

* Public health as a subject should be taught at all levels of education. Graduates in this field should be given appropriate jobs in various government departments. Each medical college should have a chair of public health.

* Existing public health laws should be strictly enforced and new laws made to achieve the objective of public health in various areas of trade and commerce.

* Specified areas should be allocated for vegetable, meat, poultry and fish markets. These markets should have some basic criteria of ventilation, cleanliness, sewerage and waste disposable.

* All involved in food processing, cooking and distribution, like cooks, bakers, confectioners, must have periodic medical checkup and should have a certificate of freedom from major communicable diseases.

* All trades and professions which have a bearing on the public health should be registered with relevant bodies. Their registration should be subject to review and not on an indefinite basis.

* Industries that are a source of noise, pollution and chemical waste should be away from residential areas. Most inner-cities have such numerous factories in crowded residential areas, jeopardizing the health of entire vicinity.

* If the nation spends just 10 percent of its expenditure, on drugs and hospitals, in public health, we can get rid of communicable disease and various other ailments.

* Tobacco kills a smoker every 8 seconds. The advertising and promotion of tobacco products should be strictly banned.

* Regionalization of health care services in an integrated manner with functional specificity for each level of care is an essential step. Integration of current vertical programs within the framework of a need-based comprehensive primary health care system is another necessary step. Most importantly, fostering a public-private partnership to share the cost of basic primary health care and public health services must be an integral part of any reform. Introducing required regulations in the private medical sector is also needed.

* Government must also make the health care system more gender sensitive through appropriate training programs for the service providers along with wide community participation in decision-making processes. Relevant WHO/World Bank/UNDP developed tools could be extremely useful in this respect.

* Streamlining of the health care delivery and management system should be focused and there ought to be effective coordination to ensure availability of human resource for health services which in turn ascertains the availability of essential health service to people. Prevention of epidemics, Preparedness for disaster management and operationalization of surveillance system is required to be an essential component of the plan.

* Doctors should be motivated by providing incentives so as to use their optimum services. There should be a non political and professional career path devised for doctors and other people in related fields which envisage a new direction and discipline for paramedical staff also. Mobility of the doctors should be ensured so as to avert trapping of a few people in some areas.

* The plans made and the expenditure incurred on health services should be evaluated and monitored vigilantly so as to revive and upgrade the primary healthcare system and sustain the standard of services. The real test lies in their impact upon the health of the poor. However it is blood curding to know that there is a lag between the expenditure incurred on health services and the final outcome on health indicators.

* Investment in human capital can help to break the cycle of ill health and poverty. Pakistani health care requires expansion and improvement with a rural focus and strengthening partnerships with civil society.

CONCLUSION:

The gist of the discussion is that the government should not disengage itself from its responsibility of providing healthcare to the people. Primary healthcare, which is universally recognized as the people's right, is not to be neglected and tertiary care should not be allowed to go by default to the private sector. Supply of potable water, public hygiene, preventive medicine, anti-malaria and tuberculosis campaigns, environmental protection and other similar issues are basic to the primary health of the people and do not really cost much. But they are to be top priorities on the list of the government's plans. This attention will have a profound impact on the health of the people which suffers badly causing the cost of healthcare to escalate.

Health has been identified as one of the most important factors in Pakistan's low ranking in the United Nation's competitiveness index. Economists and health professionals in Pakistan have known this all along, though the government in its wisdom has chosen not to do anything about it. The pervasive impact of the poor health of the people on the economy not only takes the form of heavy expenditure in the health sector, it also translates into high absenteeism at work places, inability to cope with work and lethargy that robs people of their motivation and interest in life. How can such a person be expected to be productive? Moreover, a good health delivery system also helps in poverty reduction and is basic to a humanitarian approach. Although emphasis has been on accelerating the economic growth rate for human development and poverty reduction but it is not enough. It also requires more effective use of existing resources to deliver the basic services to the poor. The rural poor who are about 39 percent below official poverty line or 40 million of total population badly need an improvement in health services, which would help them to get out of poverty and ensure healthy lives for their children.