This study was prepared with the help of Dr Sher Shah Syed, Pakistan Medical Association, and Daily Dawn Pakistan in 2004.
PAKISTAN AND HEALTH
POPULATION: 150,694, 740.
AGE STRUCTURE:
0-14 Years: 39.3% {Male 30, 469,958; Female 28, 726,776}
15-64 Year: 56.5 % {Male 43,571,093; Female 41,651, 872}
65 AND OVER:
4.2% {Male 3, 051,674; Female 3,229,367}
MEDIAN AGE:
Total 19.8 Years. {Male: 19.7 years; Female 20 years}
ENVIRONMENT CURRENT ISSUES:
Water pollution from raw sewage, industrial wastes, and agricultural run off; limited natural fresh water resources a majority of the population does not have access to potable water; Deforestation; soil erosion; desertification.
CLIMATE:
Mostly hot, dry desert; temperate in North West; arctic in north.
POPULATION GROWTH RATE:
2.01%.
BIRTH RATE:
29.59 Births/1,000 Population.
DEATH RATE:
8.79 Deaths/1,000 Population.
SEX RATIO:
At Birth:
1.05 Male (s) Female under 15 Years: 1.06 Male (s) Female 15-64 Years: 1.05 Male (s) Female 65 Years and over: 0.94 Male (s) Female total Population: 1.05.
INFANT MORTALITY RATE:
Total: 76.53 deaths/1,000 live births. Female: 76.09 deaths/1,000 live births.
LIFE EXPECTANCY AT BIRTH:
Total Population 62.2 Years: Male: 61.3 Years, female 63.14 Years.
TOTAL FERTILITY RATE:
4.1 Children born/women.
HIV/AIDS {ADULT PREVALANCE RATE}:
0.1%.
HIV/AIDS {PEOPLE LIVING WITH /AIDS}:
78,000.
HIV/AIDS DEATH:
4,500.
LITERACY:
Definition: Age 15 and over can read and write.
Total Population: 45.7%
Male: 59.8%
Female: 30.6%
INTERNATIONAL ORGANIZATION PARTICIPATION SPECIFICALLY HEALTH ORGANIZATION
{IN RESPECT OF FINANCIAL AID}:
WB, IMF, ADB, WHO, UNESCO, UNO ETC.ETC.
PATHETIC GENERAL PICTURE:
Significance of improved health status on economic growth and prosperity of a nation was recognized even in the early stages of the development of economic theory. In fact, as early as 1890, Alfred Marshall in his famous book entitled “The Principles of Economics” noted that “health and strength, physical, mental, and moral… are the basis of industrial wealth. Given that physical, mental, and moral health of the labour force are key factors in raising their productivity and that impact of these factors on the economic development is a long term issue, in this paper we have, therefore, empirically tested this proposition within the framework of the recently proposed “co-integration” technique exclusively designed for testing long run relationship.
The policy makers should give priority towards controlling the population growth (fertility) and provide better health services so as to improve the life expectancy of the people. Investing society’s scarce resources in this health related factors may have a long lasting impact on the country’s economic prosperity. Currently a lot of hue and cry is being made about the so-called inefficiency of the public healthcare system. The government claims that state ownership is to blame!! The truth is that it is inefficient because the government wants it to be inefficient in order to more easily get rid of it! How can any healthcare system be efficient when the money allocated to it in the state budget amounts to only 0.7% of GDP when it should be at least 4 to 6%? Where there should be one nurse for every four patients there is only one for every 40 in tertiary care hospitals. Where there should be one doctor for every seven beds, there is only one doctor for every 60 beds!
A doctor should only have to work an 8 hour shift, but doctors usually have to work between 36 and 72 hours in a single shift, mostly unpaid!! To add to this, the recruitment of doctors has now been banned for more than 20 years. How could a system be efficient in these conditions? Instead of giving long awaited jobs, millions of rupees are spent to create boards of governors and dummy universities. In a country where 70 out of 1000 newborn children die and 60 mothers out of 1000 die during childbirth, the lion’s share of the national income goes on buying weapons! The majority of people and especially children die of diseases that are totally curable and preventable such as diarrhoea, pneumonia, tuberculosis, etc.
In a country where most people earn less than 3000 rupees per month we have medical colleges charging between 1.5 and 2 million for a medical graduation. However, awareness is growing and the people are now beginning to understand the true nature of capitalism. 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. It is most unfortunate that while we are opening new hospitals and introducing state of the art technology, and human expertise. We are doing nothing about the dismal state of public health in Pakistan.
According to a leading donor agency’s report, ‘the Health Sector in Pakistanis infested with lack of efficiency, misallocation of resources, leakages, political influence, poor management and centralized financial, administrative and management authority. Thus inefficiency and cost ineffectiveness are perhaps the two basic impediments to a better health care system. A comparison with some other countries in the region shows that Pakistan’s performance in the health sector is unfavourable. For instance, the expenditure on health by the government is only 0.2% of the GNP compared to 0.7% for Bangladesh, 0.9% for Nepal and 1.4% for Sri Lanka, each with per capita incomes substantially below Pakistan’s. The life is only 59 years compared to 71 years, the Crude Birth Rate is 41, Crude Death Rate is 11 and the Infant Mortality Rate is 97. Comparable figures for Sri Lanka are 71, 21, 6 and 18. Inefficiency is widely regarded as a central problem in the health and population sector in Pakistan…. (Especially) in the public sector. Resources are misallocated, in part because no investigation has typically been made into the cost-ineffectiveness of various options. Political influence and leakage of equipment and supplies further distort public sector allocations. Poor management and centralized financial, administrative and management authority reduces the efficiency of facility-level staff services.
In other words, given the limited available budget, should the public health department (PHD) go for an expanded infrastructure program (developmental expenditure) or hire more health personnel (recurring expenditure) or a combination of both so that there is a real improvement in the health services? Or, even more importantly, what type of wage policy should it adopt if more personnel are needed to work in rural health centres (RHCs), basic health units (BHUs) and hospitals, especially when there are shortages of competent nurses and doctors in the country?
HEALTH STRUCTURE IN PAKISTAN:
The health and demographic characteristics in Pakistan are substantially worse than those of other countries in the region. Maternal mortality rate is high (6 per 1000), as is infant mortality (103 per 1000 live birth). Malnutrition is widespread (50% of children are stunted) and life expectancy is certainly one of the lowest in the region (56 years for men and 55 years for women). Pakistan has one of the highest population growth rates in ASIA (3.1% per year) with very little evidence of a fertility decline while this is largely because of poverty, poor sanitation and water supply and low levels of literacy, particularly among women (21%), it nevertheless also reflects serious shortcomings in health policy and the design and operation of health care services and facilities.
Public expenditure on health has been increasing over time, but is only a very small proportion of the GNP. Overall percapita health care spending (inclusive of private expenditure) compares favourably with the other countries in Asia, but the quality is much lower. The private health care facilities are concentrated largely in the urban areas and are used mostly by the well off. Coverage in the rural area is poor, even by the public health care services. The main health care issue, therefore, is how to provide a cost-effective service to the majority of the people. Could this be by increasing public expenditure, ensuring greater cost recovery, improving the efficiency of publicly financed health care, encouraging the private sector where it has comparative advantage and/or encouraging the use of risk-sharing schemes to cover more people? Health policy is determined by the federal Ministry of Health, but services (except for a few specialists’ hospitals and clinics) are provided by the provincial departments of Health, Nutrition Policy is determined by the Planning Division, Population and family planning services are provided by both the federal ministry and the provincial departments of Population Welfare. Coordination is limited. Even though hospitals are continuing to receive the largest share of public sector health expenditure (45%), they often continue to operate inefficiently and ineffectively. Very high out patient attendance at these hospitals is the result of patients by passing the basic health care facilities where the service quality is seen to be very poor, marred by absence of both staff and medication, on the one hand, and poor sitting, on the other.
This depletes the already meager resources available to the hospitals (in man, medicine and facilities) and thus leads to greater inefficiency in the system. The public sector provision of services is further weakened as a large part of the medical personnel, particularly the senior doctors and specialists {read BUTCHERS}; own their own hospitals, clinics, MCH Centres and laboratories to which supplicants for their services are directed. The PMDC feels that as much as half or more of the private sector facilities are operated by these “publicly employed” personnel. The Private sector health care facilities cater to about a quarter of the patients treated in hospitals, but the conditions in the smaller hospitals are generally only marginally better than in public hospitals, for instance, patients are expected to provide their own food and attendants and in some instances also medication which may be purchased from on-site “self-owned” pharmacies. Most of these pharmacies, as also all off-site or independent pharmacies and medical stores are staffed by inadequately trained staff. Instances of a qualified pharmacists being jointly by a number of spatially distributed pharmacies is not uncommon.
Similarly a number of doctors, particularly specialists, are found to be on the panel of medical personnel at more than one private sector facility. Private hospitals are mostly concentrated in the nine big cities of Pakistan. These cities account for more than 75% of private sector hospital beds. The qualities of care in the larger hospitals are reasonable to good, but in the smaller hospitals the quality is poor. This is seen from the outdated equipment, the use of rented housing units and the non-availability of sufficient qualified nursing and paramedic staff because of low salaries and insecure employment conditions offered.
Medical professionals conducted a survey in the mid-nineties and the saddest thing is that even in 2004 the situation is not very different.
Health Professionals in the Country
Category Number
Doctors 33,584
Dentists 999
Nurses 10,554
Lady Health Visitors 2,562
Nurses Midwives 5,275
Sister tutors 290
Ward Administrators 535
Medical Technologists 115
Physiotherapists 119
Dispensers 17,370
Sanitary Inspectors 1,974
Malaria Inspectors 1,601
Pharmacy Graduates 1,743
Production of Health Professionals in Pakistan
Cadre, Demand, Present Staff, 10 Year Output, Supply, Total Difference
Medical
Specialists 11,365 1,425 3,100 4,500 - 7000
Nurses 23,730 6,050 11,850 18,000 - 5700
Medical
Technician 14,400 2,500 7,300 10,000 - 4500
LHV 2,700 1,750 1,900 3,650 + 1000
Total 52,195 11,715 24,150 36,150 16,200
Present Output of Professionals
Category No of Institutions Present Output Output 1970
Doctors 17 4000 800
Postgraduates 4 150 70
Nurses 47 850 300
Nurse Teachers 1 60 20
Lady Health Visitors 10 600 200
Nurses Midwives 58 675 200
Medical Technicians 26 600 Nil
Dispensers 50 1500 500
Sanitary Inspectors 1 1 100
Health Facilities
Year Hospitals Dispensaries BHUs Maternity C. RHUs TB C. Beds H. R.Dr.
1991 774 4,007 4,384 1,057 464 219 75,552 55,572
Year R.Dentists R.Nurses R.Midwives R.LHVs Beds H. Dr./Pop Dentists Expenses
1991 2,193 18,150 16,299 3,463 1,506 2,008 51,789 2,707M
The situation is in state where people have forgotten what public health means and what is the scope of public health measures in the overall well being of the society. One of the basic aspects of public is the formation of and implementation of rules and regulations governing the production, preparation and sale of eatables under hygienic environments and that too with due medical specification. Even after the passage of five decades and above all becoming a “Nuclear Power”, the public health status of the nation has only deteriorated and is one of the worst in the world. When even in a city like Karachi, one can find hospitals a shape which we would not even like to use as a toilet then what to talk of up country. The state has a responsibility to help the community maintain standards of health and avoid the avoidable diseases.
Restaurants, hotels, schools, jails, factories, offices and other places where a large number of people live or spend substantial time along with others, provide ample opportunities for the spread of certain diseases. When we cannot even provide clean potable running water to the majority of the people then how can we expect a modern health system in Pakistan?
There exists no system in place to monitor these places or provide the basic know how of healthy living to those who are exposed to diseases. These measures do not cost much but can identify people at risk and teach them as to how to protect themselves. Routine Medical Checkups, of people directly involved e.g. with the food process, needs to be enforced to stop the spread of disease from the infected or carrier subjects to healthy individuals. Since we call ourselves Muslims and our society an Islamic one then we must follow the maxim “Cleanliness is next to Godliness”. It seems that this motto has been absent from our society and we are virtually living in garbage. For Example certain professionals prone to the spread of communicable disease are barbers, cooks, bakers, and sweet merchants etc. A single baseline medical checkup of these individuals can unmask a number of diseases. Their timely treatment will not only save the lives of these poor bread earners, but will also protect those who are in contact with them. In the complete absence of any monitoring, check and balance and preventive measures, our people are living at the mercy of nature. It is time that various governmental agencies working at different level sense a wake up call and realizes their responsibilities towards the public health of the society. Regulatory authorities do exist at various administrative levels. Unfortunately, they do not live up to their responsibilities.
The public’s perception of health revolves around therapeutic modalities only. The masses are unaware of the role played by simple ways and means in disease prevention. They are ignorant of the potential of public health measures. It is simply a shame that a country like ours, with reasonable resources and infrastructure has one of the poorest public health standards in the world. The medical profession, media and governmental agencies have to act in an integrated way to change this appalling situation. What we are doing in the health sector goes totally to waste in the absence of common sense public health measures. For example city district government of Karachi and Lahore, with sizeable human and financial resources should adopt a comprehensive public health policy. This will act as a model for other cities, towns and tehsils to follow. If we fail to evolve a rational public health system in the country, the huge burden of Communicable Disease will remain our liability in addition to the disease of modern age such as heart diseases, strokes, diabetes and psychiatric illness. According to a leading donor agency “Health outcomes and services in Pakistan have slowly improved over the past 10 years with improved availability of female staff {bias donor agencies in any particular political situation or interest may please be kept in mind} and better access to immunization and family planning services”. But Pakistan is still worse off than many other countries in terms of maternal and child mortality, malnutrition, the burden of infectious disease and high fertility. The pathetic public health sector is the main result of very low government expenditure on health services, poor value obtained by the public from what the government spends, because of weak management and corrupt practices such as absenteeism so on, poor quality of care from many private health care providers. Pakistan per capita income is much higher than the average lower-income countries but despite of the govt-and donor-financed interventions, health indicators have been improving with snail pace rather no pace at all.
Communicable diseases such as diarrhea, respiratory infections, tuberculosis, and immunizable childhood diseases still account for the major portion of sickness and death in Pakistan. Maternal Health problems are also wide spread, complicated in part by frequent births. In fact, Pakistan lags far behind most developing countries in women’s health and gender equity of every 38 women who give birth, 1 dies. The infant mortality rat {101 per 1,000} and the mortality rate for children under age five (140 per 1,000 births} exceeds the averages for low-income countries by 60 and 30%, respectively. Although use of contraceptives has increased, fertility remains high, at 5.3 births per woman and population growth rates are much higher than elsewhere in South Asia. The underlying problems that affect health---poverty, illiteracy, women’s low status, inadequate water supplies and sanitation---persist. Another study opines that the health status of Pakistan is characterized by a high rate of population growth and poor health indicators.
Two fundamental problems, which plague the sector, are lack of equity and effectiveness. The provision of health services is highly inequitable; although rural dwellers comprise almost two thirds of the population, the majority of health services and doctors are located in the Urban Areas. Recent attempts to offset this bias by developing primary health services in rural areas have met problems of understanding and under utilization. This has contributed to the lack of effectiveness of investments already made.
GOVERNMENT’S SO-CALLED PLANNING AND POLICY.
The Health Sector investments are viewed as part of Government’s Poverty Alleviation Plan. Priority attention is accorded to primary and secondary sectors of health to replace the earlier concentration on Tertiary Care. Good governance is seen as the basis of health sector reform to achieve quality health care.
There are 10 major areas which the Government of Pakistan wants to revamp:
1- Reducing widespread prevalence of communicable diseases.
2- Addressing inadequacies in primary/secondary health care services.
3- Removing professionals/managerial deficiencies in the District Health System.
4- Promoting greater gender equity.
5- Bridging basic nutrition gaps in the target-population.
6- Correcting urban bias in health sector.
7- Introducing required regulation in private medical sector.
8- Creating Mass Awareness in Public Health matters.
9- Effecting Improvements in the Drug Sector.
10- Capacity-building for Health Policy Monitoring.
IMPLEMENTATION OF THE PLAN.
To reduce the widespread prevalence of communicable diseases (i.e. EPI cluster of childhood diseases, TB, Malaria, Hepatitis-B, and HIV-AIDS) following measures are to be taken:
The preventive and promotive health programmes will be implemented as National Programmes with clear cut Federal/Provincial spheres of responsibility. The Federal Government will assist in planning, monitoring, evaluation, training and research activities while the Provincial Governments will undertake service delivery. The National Programme on EPI will be expanded through introduction of Hepatitis-B vaccine. Routine EPI facilities in the Provinces, especially cold-chain equipment will be strengthened through GAVI’S grant assistance over the next 5 years. A National Programme for immunizing mothers against National Tetanus will be implemented in 57 selected High-Risk Districts of the country over 3years. A national programme will be launched against Tuberculosis based on DOTS {Directly Observed Treatment Short Course} mode of implementation. The main feature of this are-training of federal, provincial and district level managers; case detection through sputum smear technology; observed treatment of patients; standardized drug regime and operational research. A new national malaria control programme will be implementerd, focusing on malaria microscopy through upgraded basic health facilities; and early diagnosis with prompt treatment. Mass spraying will be replaced by selective sprays only. The current PC-I on HIV-AIDS will be enlarged to incorporate the following components-prevention of HIV transmission through health education; surveillance system; early detection of Sexually Transmitted Infections (STIs); Improved Care of the Affected Persons; and promotion of Safe Blood Transfusion.
A uniform law will be enacted to set up Blood Control Authorities in the Provinces.
To address Inadequacies in Primary/Secondary Health Care Services:
The main inadequacies are identified as the deficient state of equipment and medical personnel at BHU/RHC level. Absenteesim is common. At the district/tehsil level hospitals there are major shortcomings in emergency care, surgical services, anaesthesia and laboratory facilities. There is no referral system in operation.
HEALTH STRUCTURE IN PAKISTAN:
The health and demographic characteristics in Pakistan are substantially worse than those of other countries in the region. Maternal mortality rate is high (6 per 1000), as is infant mortality (103 per 1000 live birth). Malnutrition is widespread (50% of children are stunted) and life expectancy is certainly one of the lowest in the region (56 years for men and 55 years for women). Pakistan has one of the highest population growth rates in ASIA (3.1% per year) with very little evidence of a fertility decline while this is largely because of poverty, poor sanitation and water supply and low levels of literacy, particularly among women (21%), it nevertheless also reflects serious shortcomings in health policy and the design and operation of health care services and facilities.
Public expenditure on health has been increasing over time, but is only a very small proportion of the GNP. Overall percapita health care spending (inclusive of private expenditure) compares favourably with the other countries in Asia, but the quality is much lower. The private health care facilities are concentrated largely in the urban areas and are used mostly by the well off. Coverage in the rural area is poor, even by the public health care services. The main health care issue, therefore, is how to provide a cost-effective service to the majority of the people. Could this be by increasing public expenditure, ensuring greater cost recovery, improving the efficiency of publicly financed health care, encouraging the private sector where it has comparative advantage and/or encouraging the use of risk-sharing schemes to cover more people? Health policy is determined by the federal Ministry of Health, but services (except for a few specialists’ hospitals and clinics) are provided by the provincial departments of Health, Nutrition Policy is determined by the Planning Division, Population and family planning services are provided by both the federal ministry and the provincial departments of Population Welfare. Coordination is limited. Even though hospitals are continuing to receive the largest share of public sector health expenditure (45%), they often continue to operate inefficiently and ineffectively. Very high out patient attendance at these hospitals is the result of patients by passing the basic health care facilities where the service quality is seen to be very poor, marred by absence of both staff and medication, on the one hand, and poor sitting, on the other.
This depletes the already meager resources available to the hospitals (in man, medicine and facilities) and thus leads to greater inefficiency in the system. The public sector provision of services is further weakened as a large part of the medical personnel, particularly the senior doctors and specialists {read BUTCHERS}; own their own hospitals, clinics, MCH Centres and laboratories to which supplicants for their services are directed. The PMDC feels that as much as half or more of the private sector facilities are operated by these “publicly employed” personnel. The Private sector health care facilities cater to about a quarter of the patients treated in hospitals, but the conditions in the smaller hospitals are generally only marginally better than in public hospitals, for instance, patients are expected to provide their own food and attendants and in some instances also medication which may be purchased from on-site “self-owned” pharmacies. Most of these pharmacies, as also all off-site or independent pharmacies and medical stores are staffed by inadequately trained staff. Instances of a qualified pharmacists being jointly by a number of spatially distributed pharmacies is not uncommon.
Similarly a number of doctors, particularly specialists, are found to be on the panel of medical personnel at more than one private sector facility. Private hospitals are mostly concentrated in the nine big cities of Pakistan. These cities account for more than 75% of private sector hospital beds. The qualities of care in the larger hospitals are reasonable to good, but in the smaller hospitals the quality is poor. This is seen from the outdated equipment, the use of rented housing units and the non-availability of sufficient qualified nursing and paramedic staff because of low salaries and insecure employment conditions offered.
Medical professionals conducted a survey in the mid-nineties and the saddest thing is that even in 2004 the situation is not very different.
Health Professionals in the Country
Category Number
Doctors 33,584
Dentists 999
Nurses 10,554
Lady Health Visitors 2,562
Nurses Midwives 5,275
Sister tutors 290
Ward Administrators 535
Medical Technologists 115
Physiotherapists 119
Dispensers 17,370
Sanitary Inspectors 1,974
Malaria Inspectors 1,601
Pharmacy Graduates 1,743
Production of Health Professionals in Pakistan
Cadre, Demand, Present Staff, 10 Year Output, Supply, Total Difference
Medical
Specialists 11,365 1,425 3,100 4,500 - 7000
Nurses 23,730 6,050 11,850 18,000 - 5700
Medical
Technician 14,400 2,500 7,300 10,000 - 4500
LHV 2,700 1,750 1,900 3,650 + 1000
Total 52,195 11,715 24,150 36,150 16,200
Present Output of Professionals
Category No of Institutions Present Output Output 1970
Doctors 17 4000 800
Postgraduates 4 150 70
Nurses 47 850 300
Nurse Teachers 1 60 20
Lady Health Visitors 10 600 200
Nurses Midwives 58 675 200
Medical Technicians 26 600 Nil
Dispensers 50 1500 500
Sanitary Inspectors 1 1 100
Health Facilities
Year Hospitals Dispensaries BHUs Maternity C. RHUs TB C. Beds H. R.Dr.
1991 774 4,007 4,384 1,057 464 219 75,552 55,572
Year R.Dentists R.Nurses R.Midwives R.LHVs Beds H. Dr./Pop Dentists Expenses
1991 2,193 18,150 16,299 3,463 1,506 2,008 51,789 2,707M
The situation is in state where people have forgotten what public health means and what is the scope of public health measures in the overall well being of the society. One of the basic aspects of public is the formation of and implementation of rules and regulations governing the production, preparation and sale of eatables under hygienic environments and that too with due medical specification. Even after the passage of five decades and above all becoming a “Nuclear Power”, the public health status of the nation has only deteriorated and is one of the worst in the world. When even in a city like Karachi, one can find hospitals a shape which we would not even like to use as a toilet then what to talk of up country. The state has a responsibility to help the community maintain standards of health and avoid the avoidable diseases.
Restaurants, hotels, schools, jails, factories, offices and other places where a large number of people live or spend substantial time along with others, provide ample opportunities for the spread of certain diseases. When we cannot even provide clean potable running water to the majority of the people then how can we expect a modern health system in Pakistan?
There exists no system in place to monitor these places or provide the basic know how of healthy living to those who are exposed to diseases. These measures do not cost much but can identify people at risk and teach them as to how to protect themselves. Routine Medical Checkups, of people directly involved e.g. with the food process, needs to be enforced to stop the spread of disease from the infected or carrier subjects to healthy individuals. Since we call ourselves Muslims and our society an Islamic one then we must follow the maxim “Cleanliness is next to Godliness”. It seems that this motto has been absent from our society and we are virtually living in garbage. For Example certain professionals prone to the spread of communicable disease are barbers, cooks, bakers, and sweet merchants etc. A single baseline medical checkup of these individuals can unmask a number of diseases. Their timely treatment will not only save the lives of these poor bread earners, but will also protect those who are in contact with them. In the complete absence of any monitoring, check and balance and preventive measures, our people are living at the mercy of nature. It is time that various governmental agencies working at different level sense a wake up call and realizes their responsibilities towards the public health of the society. Regulatory authorities do exist at various administrative levels. Unfortunately, they do not live up to their responsibilities.
The public’s perception of health revolves around therapeutic modalities only. The masses are unaware of the role played by simple ways and means in disease prevention. They are ignorant of the potential of public health measures. It is simply a shame that a country like ours, with reasonable resources and infrastructure has one of the poorest public health standards in the world. The medical profession, media and governmental agencies have to act in an integrated way to change this appalling situation. What we are doing in the health sector goes totally to waste in the absence of common sense public health measures. For example city district government of Karachi and Lahore, with sizeable human and financial resources should adopt a comprehensive public health policy. This will act as a model for other cities, towns and tehsils to follow. If we fail to evolve a rational public health system in the country, the huge burden of Communicable Disease will remain our liability in addition to the disease of modern age such as heart diseases, strokes, diabetes and psychiatric illness. According to a leading donor agency “Health outcomes and services in Pakistan have slowly improved over the past 10 years with improved availability of female staff {bias donor agencies in any particular political situation or interest may please be kept in mind} and better access to immunization and family planning services”. But Pakistan is still worse off than many other countries in terms of maternal and child mortality, malnutrition, the burden of infectious disease and high fertility. The pathetic public health sector is the main result of very low government expenditure on health services, poor value obtained by the public from what the government spends, because of weak management and corrupt practices such as absenteeism so on, poor quality of care from many private health care providers. Pakistan per capita income is much higher than the average lower-income countries but despite of the govt-and donor-financed interventions, health indicators have been improving with snail pace rather no pace at all.
Communicable diseases such as diarrhea, respiratory infections, tuberculosis, and immunizable childhood diseases still account for the major portion of sickness and death in Pakistan. Maternal Health problems are also wide spread, complicated in part by frequent births. In fact, Pakistan lags far behind most developing countries in women’s health and gender equity of every 38 women who give birth, 1 dies. The infant mortality rat {101 per 1,000} and the mortality rate for children under age five (140 per 1,000 births} exceeds the averages for low-income countries by 60 and 30%, respectively. Although use of contraceptives has increased, fertility remains high, at 5.3 births per woman and population growth rates are much higher than elsewhere in South Asia. The underlying problems that affect health---poverty, illiteracy, women’s low status, inadequate water supplies and sanitation---persist. Another study opines that the health status of Pakistan is characterized by a high rate of population growth and poor health indicators.
Two fundamental problems, which plague the sector, are lack of equity and effectiveness. The provision of health services is highly inequitable; although rural dwellers comprise almost two thirds of the population, the majority of health services and doctors are located in the Urban Areas. Recent attempts to offset this bias by developing primary health services in rural areas have met problems of understanding and under utilization. This has contributed to the lack of effectiveness of investments already made.
GOVERNMENT’S SO-CALLED PLANNING AND POLICY.
The Health Sector investments are viewed as part of Government’s Poverty Alleviation Plan. Priority attention is accorded to primary and secondary sectors of health to replace the earlier concentration on Tertiary Care. Good governance is seen as the basis of health sector reform to achieve quality health care.
There are 10 major areas which the Government of Pakistan wants to revamp:
1- Reducing widespread prevalence of communicable diseases.
2- Addressing inadequacies in primary/secondary health care services.
3- Removing professionals/managerial deficiencies in the District Health System.
4- Promoting greater gender equity.
5- Bridging basic nutrition gaps in the target-population.
6- Correcting urban bias in health sector.
7- Introducing required regulation in private medical sector.
8- Creating Mass Awareness in Public Health matters.
9- Effecting Improvements in the Drug Sector.
10- Capacity-building for Health Policy Monitoring.
IMPLEMENTATION OF THE PLAN.
To reduce the widespread prevalence of communicable diseases (i.e. EPI cluster of childhood diseases, TB, Malaria, Hepatitis-B, and HIV-AIDS) following measures are to be taken:
The preventive and promotive health programmes will be implemented as National Programmes with clear cut Federal/Provincial spheres of responsibility. The Federal Government will assist in planning, monitoring, evaluation, training and research activities while the Provincial Governments will undertake service delivery. The National Programme on EPI will be expanded through introduction of Hepatitis-B vaccine. Routine EPI facilities in the Provinces, especially cold-chain equipment will be strengthened through GAVI’S grant assistance over the next 5 years. A National Programme for immunizing mothers against National Tetanus will be implemented in 57 selected High-Risk Districts of the country over 3years. A national programme will be launched against Tuberculosis based on DOTS {Directly Observed Treatment Short Course} mode of implementation. The main feature of this are-training of federal, provincial and district level managers; case detection through sputum smear technology; observed treatment of patients; standardized drug regime and operational research. A new national malaria control programme will be implementerd, focusing on malaria microscopy through upgraded basic health facilities; and early diagnosis with prompt treatment. Mass spraying will be replaced by selective sprays only. The current PC-I on HIV-AIDS will be enlarged to incorporate the following components-prevention of HIV transmission through health education; surveillance system; early detection of Sexually Transmitted Infections (STIs); Improved Care of the Affected Persons; and promotion of Safe Blood Transfusion.
A uniform law will be enacted to set up Blood Control Authorities in the Provinces.
To address Inadequacies in Primary/Secondary Health Care Services:
The main inadequacies are identified as the deficient state of equipment and medical personnel at BHU/RHC level. Absenteesim is common. At the district/tehsil level hospitals there are major shortcomings in emergency care, surgical services, anaesthesia and laboratory facilities. There is no referral system in operation.
Trained Lady Health Workers will be utilized to cover the un-served population at the primary level. This would ensure family planning and primary health care services at the doorstep of the populationj through and integrated community based approach; 58,000 Lady Health Workers under Health Ministry and 13,000 Village-based Family Planning Workers under Population Welfare Ministry will be integrated to create a cadre of 71,000 Family Health Workers under National Programme for Family Planning and Primary Health Care. This cadre will be increased to 100,000 by the year 2005. Provinces will undertake improvement of District/Tehsil Hospitals under a phased plan. A minimum of 6 specialties (Medicine, Surgery, Paediatrics, Gynae, ENT and Ophthalmology) will be made available at these facilities. District and Tehsil Hospitals will be upgraded to the desired standard through Provincial Master Plans.
The Provincial Governments have prepared the following hospitals up gradation plan:
Sindh 11 District Hospitals and 44 Taluka Hospitals at a cost of Rs. 330 Million.
Punjab 25 District Hospitals and 52 Tehsil Hospitals at a cost of Rs. 1665 Million.
NWFP 19 District Hospitals and 11 Tehsil Hospitals at a cost of Rs. 989 Million.
Baluchistan 3 District Hospitals and 30 Tehsil Hospitals at a cost of Rs. 540
Million.
UNHEALTHY BUDGET FOR HEALTH SECTOR:
Pakistan’s share of total health expenditure to gross national product has never exceeded 0.8% per annum [Economic Survey 1992-93], which is significantly lower than many of its neighbouring countries in the region. If the future is any reflection of past history, then one does not expect substantial public funds to be forthcoming and diverted towards this sector in the immediate medium term future especially when the country is already experiencing large and increasing budgetary deficits. Prudent public policy research in this context, based on realistic pragmatic approach, should then be geared towards an investigation into measures to improve the present Public Health System (PHS) through an efficient, cost-effective reallocation of health inputs with in the existing limited budget. The growth of health infrastructure building in the urban area may be pursued but one must give extra resource allocation toward the rural sector. Attractive wage policies be formulated for personnel {doctors/paramedics} e.g. the status of nurses in the Public Health System be elevated by giving them higher BPS. Facilities may be provided as in the case of Armed forces.
Those in government never get tired of telling everyone that economy is not just on the right track, it is in fact, ready to take off. The nation, for sure, has been waiting with fastened seat belts for this promised take off that has yet to come. Jugglery with statistics is something the bureaucracy is quite expert at doing. Give them a target, and they can find a statistic to prove their case. Ask them to show a downward trend in terms of inflation, and they will find a formula to show it is actually down. GNP, GDP, Debt-servicing, tax collection, revenue generation, give them any task; the result will be what you want. That much is guaranteed. All governments have made full use of such a competent bureaucracy and this is the nomenclature of Pakistan since 1947. Even though public expenditure on health has been increasing over time from Rs. 727 Million in 1980 to Rs. 6, 035 Million in 1992, it represents only a very small proportion of the GNP (0.7% to 0.8% over the period). Per bed expenditure in current terms has increased from Rs. 11, 000 per bed-year in 1980 to Rs. 46,000 per bed-year in 1991 that is at annual rate of 14.4%. Expressed as per patient costs the anuual increase has been at a rate of 11.2 % in nominal terms. On the other hand, cost recovery ratio is very low declining from 4.9% in 1980 to 3.5% in 1992.
In recent years, many developing countries have invested heavily on the social sector including basic health. This is based on the premise that human capital is vital to the growth and development of a nation. Therefore, keeping the mass healthy is as important as providing them with basic education. Pakistan had an impressive GDP growth rate of about 8% per annum in 1991-92, out of which only a meager 0.2% was spent on the health sector by the central govt. when this figure is translated in monetary value, it amounts to only Rs.2 per 1000/. Rupees of GNP spent on health sector. This amount is very little by any standard and, in fact, the picture is even more dismal when this figure is compared with those of other developing countries of the eight countries selected for comparison, Bangladesh, and Sri Lanka appeared to have spent 4.8% of their govt. expenditure on health as opposed to only 1% by Pakistan. Even a small, poor country like Nepal spends more money (4.7%) than Pakistan on the health sector. Pakistan’s standing in terms of spending on health (either as a proportion of govt. expenditure or GNP) is the lowest which is very discouraging and disappointing. Low public expenditure on health facilities over the years is also reflected in the poor health status of the population and dismal public health sector in Pakistan. Health indicators on life expectancy, crude birth rate, crude death rate and infant mortality rate indicate that Sri Lanka and Malaysia have the highest life expectancy at birth 71 years while, for Pakistan, the figure is only 59 years. In terms of CBR, Pakistan has the highest rate of 41 per thousand populations, which is one of the reasons for the high population in the country. Sri Lanka again has the lowest crude birth rate at 21 per thousand population followed by Indonesia (25), Philippines (28), and Malaysia (29), however, with respect to crude birth rate, Pakistan’s standing is little better among one of the three highest countries (i.e. at per thousand population) in the region.
The infant mortality rates across different countries, it appears that more than 97 babies per thousand newborns in Pakistan do not get to see the face of the earth as opposed to only 15 per thousand newborns in Malaysia. Child malnutrition measures the percentage of children under five with a deficiency or an excess of nutrients that interfere with their health and genetic potential for growth. Malnutrition continues to be a major problem for third world countries. More than half of all children suffer stunting and wasting despite the increase in the growth of agriculture and industry, the prevalence of malnutrition in Pakistan remain unchanged. Countries like Indonesia, Philippines, and Egypt have all dramatically lowered their rates of malnutrition in the last 10 to 20 years. It is crystal clear that Pakistan’s performance in the health sector is less than adequate. Furthermore, Pakistan’s spending for this sector is also one of the lowest in the region.
In the present environment of budget deficits, the critical issue facing the public sector should then pertain to designing health policies which must be cost-effective and efficient.
VITAL STATISTICS:
Central Government Expenditure on Health for Selected Developing countries.
Country %of Total Cent.Govt. Expenditure on Health %of GNP spent on Health
Pakistan - 1.0 - 0.2
Bangladesh - 4.8 - 0.7
Nepal - 4.7 - 0.9
India - 1.6 - 0.3
Sri Lanka - 4.8 - 1.4
Indonesia - 2.4 - 0.5
Egypt - 2.8 - 1.1
Philippines - 4.2 - 0.8
Trends of Expenditure Outlays of Selected Countries
Country GNP per capita Military Exp. Public Exp. Public Exp.
(USS) (as %of GDP) on Health on Education (as % of GNP)
1966-1990 1960-1990 1960-1990 1960-1990
Pakistan 120 400 5.5 6.6 0.3 4.5 1.1 3.4
India 90 360 1.9 3.3 0.5 3.2 2.3 3.2
Bangladesh 70 210 - 1.6 - 0.9 0.6 2.2
Sri Lanka 170 470 1 4.8 2 2.3 3.8 2.7
Basic Social Indicators for selected Developing Countries.
Country Life Expectancy at Birth. Crude Crude Infant
(in Years) Birth Death Mortality
Rate Rate Rate
Pakistan 59 41 11 97
Bangladesh 51 34 13 103
Nepal 53 38 13 101
India 60 30 10 90
Sri Lanka 71 21 6 18
Indonesia 60 25 9 74
Egypt 61 32 9 59
Philippines 65 28 7 41
Malaysia 71 29 5 15
Indicators of Basic Health And Nutrition For Selected Developing Countries.
Country - Population per Babies with low Prevalence Daily Calorie
Physician - birth weight% of Malnutrition Supply
Nurse (under 5 Yr) (per capita)
Pakistan 2910 4900 25 57 2315
Bangladesh 6730 8980 31 60 1927
Nepal 32710 4680 - - 2052
India 2520 1700 30 - 2238
Sri Lanka 5520 1290 28 45 2400
Indonesia 9460 1260 14 14 2579
Egypt 770 780 7 13 3342
Philippines 6700 2740 18 19 2372
Malaysia 1930 1010 9 24 2730
The wait for the take off has continued, and it is likely to continue for an indefinite period. Despite the drop in debt servicing liabilities in the wake of loan write-off and rescheduling that cam Pakistan’s way for its willingness to play the American Hand in the region e.g. the 2003/2004 annual budget shows in ample terms that debt servicing and defense will still make up over half----51.68% to be exact---of the total expenditure in the new fiscal year. In the previous fiscal, the together comprised 51.87% of total expenditure. So, there has been no basic change in approach. The key social sectors like health, education and so on, will thus, continue to get the peanuts that have been their fate for long. Consider the allocation for social services under civil administration spending in 2003/2004, which is Rs. 16.40 billion. Now compare it with the rather whooping Rs. 160.25 Billion for Defence spending, and Rs. 255.96 billion for debt servicing. There is no jugglery of statistics here. These are the figures which are announced and published. A quick glance is enough to suggest the government could have easily slashed the defence and debt servicing budget by, say, Rs 5 Billion each, if not more and put it into social services. That would have made a world of difference, but, then you need to have the right poor people approach to make such adjustments.
Social services carry such enormous sectors like health and education, and the allocation for these specific areas is so minimal even peanuts look too many. Let’s just leave education, for health, it is Rs. 4.37 Billion. In contrast population welfare has got Rs. 3.11 Billion, while the importance of population welfare cannot be underrated; the allocation for the sector is just an indication of the kind of competence the budget makers use in the process. Spending in health and education sectors involved much higher structural costs in term of hospitals, schools, facilities and salaries for doctors, paramedics and teachers. It is strange that the allocation for development spending on education is more or less the same as development spending on population welfare, a sector that is not cost-intensive and, in any case, has not produced the results to deserve such an allocation. Forget about employment opportunities for young doctors, for it is like asking the government to do too much, what about, say, the improvement of drug supply to the government run hospitals? They will continue to get what they have been getting in the past, and it is easy to infer that the situation on the ground will also remain the same as it has been for long. As per a news-report quoted the official figures presented in a provincial assembly, showing what the ministers in that province had collectively spent on fuel and maintenance of their cars during last four month: Rs. 900,000. And, this is the case of a province that has the lease-holders of faith running the affairs, and who, according to their supporters, are quite prudent in their spending. What about the other three provincial assemblies, the National Assembly, the Senate, all the advisors at the various levels, the civil and military bureaucrats and all the hangers on? Give the task to some bureaucrat, and he will sure find a statistic to prove it is all happening the right way, and that the economy is about to take off. The farce continues.
CURRENT SCENARIO:
As we have already explained, traditionally it had been the policy of the government - on paper at least - to provide free health care. This all changed under the regime of Nawaz Sharif, when Pakistan officially endorsed the free trade WTO treaties. Mr Sartaj Aziz in his policy address to the national assembly announced that from then onwards the government of Pakistan would divest itself of any state property and that everything would be privatized. Over the last decade each government has been slowly moving towards this goal and trying to make this transition as smoothly as possible. The first step was to highlight the inefficiency and mismanagement of the public sector hospitals. Some high profile cases of mismanagement were publicized in the media and thus the public was brought round to the idea that private would be better. The cure the disease of public mismanagement was said to be "discipline and autonomy". Many welcomed this as they thought an improvement could be achieved by these means. However, soon the government’s intentions were made clear. In the name of "autonomy" the hospitals were asked to maintain their budget by themselves. The result was an increase in the cost of tests and treatment.
Free test were withdrawn and there was a marked increase in service charges. The whole point was to convince the public that they did not need big overcrowded government hospitals which were "costly and inefficient". They would be able to get better services from private hospitals by paying only slightly more money. The slogan was "cost for efficiency".
As all these measures were bound to create unrest among the doctors, freedom to hire and fire was granted to the "autonomous" hospitals. A board of governors was created for each of these hospitals bringing it directly under the control of the provincial secretary. Other board members were taken from representatives of the capitalist class such as mill owners. These were made familiar with the workings of a hospital, putting them in a position whereby they could take part in the bidding process. In the medical staff education and training sector the same policy was adopted. Many private medical colleges were allowed to work without reaching the standards set internationally. The PMDC has been transformed into a docile obedient institution. The medical colleges are now charging anything between 1.5 and 2 million rupees for graduation in medicine. Also the fees in the public sector medical schools have been increased to bring them more in line with the levels charge in the private sector.
This is so people will feel there is no difference when they are eventually sold off to the private sector. According to the official version Pakistan is supposed to have one of the best healthcare systems in the world. This shows what barefaced liars there are in the state. We all know that in practice it is one of the worst and the shift to private healthcare is making it even worse. They show how the Pakistani government is merely a tool in the hands of the multinational drug companies who have no interest in genuine healthcare. Their primary concern is profit. After partition Pakistan inherited a totally inadequate health care system comprising only of one medical college and a few practicing doctors, (a few civilian and military set ups also existed but these were not sufficient). Over time the system was expanded and now it has spread nationally. The system is divided into two, the public sector and the private sector.
With some exceptions the major health needs of the public are catered for by the public sector. The major infrastructure of the public health care system was set up in the 1970s. Pakistan had also endorsed the then Moscow driven "health for all by 2000" initiative which had been launched by the World Health Organization. From the villages to the cities different levels of health care were started like the "Basic health units" for the villages. The Tehsil headquarter hospital represented secondary health care, and district hospitals and teaching and referral units represented tertiary care units. Along with this a significant public health campaign was launched for the first time, keeping in view local needs and WHO guidelines to meet the target. These were: An expanded programme of immunization to eradicate the prevalent infectious diseases; Malaria control programme; Tuberculosis control programme; Family planning programme; Diarrhoea and pneumonia control programmes; and many others. To monitor all these and to achieve further improvements and make sure the policy was being applied the national institute of health was created.
Thus although subsequent governments, like Zia’s, built major health complexes they completely failed to deliver to the people what they really needed. The basic healthcare units built in large numbers were in far flung places where there was very little population and the support structures, such as schools and residences were never built so doctors and other medical staff never wanted to work there. They existed as ghost units. Nevertheless under every government the "health for all by 2000" remained official policy for the state-owned health system. And despite all the corruption and mismanagement it provided a big relief to the people of Pakistan. At present there are two exclusive health cultures. One is illness behaviour of people which which is initiated, maintained and terminated by their own dynamics and the other is health delivery culture with perceptions and behaviour of the providers determinede by their established approach.
The concept of health of common man is considerably influenced by the bio-medical model. It can best be understood by the behaviour of the patient and the physician. In developing countries whooping cough, measles, tetanus, polio and tuberculosis needs protection from vaccination but diarrhoea, dysentry, malaria, parasitic infestations, respiratory diseases, and viral encephalitis, are rampant and fill majority of hospital beds. In developed countries where such disorders have been controlled, the focus is on new killers like HIV, AIDS, Heart Disease, Vascular Lesion of Nervous System, Mental Illness, Obesity and accidents. None are likely to be amendable to any vaccine. It is therefore necessary to look far beyond a pill and even beyond a physician.
If you look at the statistic given by various international agencies, it makes for very glum reading with Pakistan’s major health indicators clearly demonstrating a large unmet need. Estimated infant mortality is 85 per 1,000 live births, under 5 mortality is 103 per 1,000 live births, and maternal mortality is 533 per 100,000. Contraceptive prevalence is only 28% and the population growth rate is 2.2% per year (compared with India’s 1.7%). Immunization rates are low with less than 60% of one ear olds fully immunized.
Twenty-six % children under 5 are moderately to severely underweight; only 1% of young children receive Vitamin A supplementation; and only 19% of household use iodized salt. Despite 5,000 graduating doctors every year, and no proper policy of control on medicines, there are some six hundred thousands quacks going about happily with their medical business. The subsequent governments as well as the Pakistan Medical and Dental Council have dismally failed in their endeavor to control the problem. And despite the National Health Policy’s vision based on the health for all approach, the Expanded Program on Immunization seems to be in doldrums. In fact, the coverage of immunization for six preventable childhood diseases has declined. We have not been able to protect our people against hazardous diseases or upgrading curative care facilities. Even after 33 sessions of Polio Campaigns, the Health Ministry has been unable to eradicate it. Pakistan is among the 22 countries that carry almost 80% of the global T.B burden. In effect, if we look at our health indicators we are, among the underdeveloped nations, perhaps just a little better off than Afghanistan and the Sub-Sahara region. According to a WB report on WOMEN HEALTH IN PAKISTAN, every year, some 30,000 women die for not getting the basic health facilities and 375,000 pregnant women suffer from various pregnancies related problems. It is a lack of good governance and non-implementation of policies.
The government without any parliamentary debate formulates policies and the politicians are hardly bothered. Health care depends directly on economic growth, our economic system is messed up, with the result that there is rampant poverty. Poverty often breeds corruption and this is true in health sector, too, where, money given by international agencies is smoothly siphoned off from legitimate projects.
The poor have large families as they see children as their insurance. Some will die and others will be undernourished and the mother’s hemoglobin will drop to as low as seven after each pregnancy. Yet, the vicious circle that they are caught up in continues. Give these same people safe, clean water, a working sewerage system, provide them with latrines and you will see half of our problems will go out of the window. Provide them with education as well, and 80% problems will be solved. It’s a very simple formula.
Cont/P-2
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