Health Sector in Pakistan - 6

PHARMACEUTICAL COMPANIES:

The age of the modern medicines begin with aspirin in 1899 and thereafter it was, the pharmaceuticals industry that ruled the roost before the entry of pharmaceutical the doctor himself was the most important therapeutic agent. Billions of dollars are poured each year by the pharmaceutical bosses in research and development to enhance the cure as well as profit. Now the medicines are more plentiful, more powerful and more dangerous; packaged beautifully, coming in fancy colors like candies. People must swallow, chew and gulp down capsules of one kind or the other, every day- a status symbol of upper class culture.

In 1962, when the FDA of the USA began to examine the 4300 prescription drugs that had appeared since the WW-2, the only two out of five were found effective. Many of the new drugs are dangerous among those that met FDA standards, a few were demonstrably better than those they were meant to replace after incurring a huge amount on research. This state of affairs remains unchanged since then. Pakistan’s drug scene is intrinsically no different, except that the size of the market, as the industry man lament, is small and expanding fast. However, the facts are different. In 1988, it was Rs. 10,000 Million. The pharmaceutical market is dominated by the multinationals accounting for about 67% share. Their net scales of 1225 products in 1990 stood at Rs. 7687 million. The local is not faring well in the face of the highly competitive, advanced, and powerful foreign pharmaceutical companies which enjoy great edge. These are about 30-40 multinationals and nearly 200 nationals, but some 40 of them being of some significance, engaged in the manufacturing operations which are mostly of processing and packaging character. A fact not accepted by them.

Despite of the fact that the Ministry of Health carry out the same old vigilance and try in vain to implement rules of the various stages of production, import and distribution of pharmaceutical products in addition to regulation of prices. Yet there exist no ethics and system. An atmosphere of anarchy features the market of medicines, and even the functioning of state-run hospitals because the Ministry officials, excluding a few are corrupt, act like parasites and demand bribes as a matter of right. Even the core issue of drug prices which every government in Islamabad whether Military or Political always pledge to keep in check but it didn’t happen and people were denied the affordable prices of drugs. The Price Control on Drugs is severely resented by the Multinational (read pharmaceuticals) as they consider it a major deterrent to their plans of investment and expansion. They want complete freedom of decision-making in fixing prices of their products and often threaten to pack up and leave this country if it is not conceded to. They contend that their prices in Pakistan are the lowest- a claim that remains controversial. The Pharma companies say that they are willing to lower the prices as desired by the govt., provided the govt. must stop treating their industry as a “Luxury Industry” and leading it with all kind of taxes and regulations. The local companies have a bonafide grievance against the multinationals; they want the over the counter drugs like Vitamins, cough mixtures, lotions, analgesic and other common medicines like paracetamol and aspirin, which happen to be their bread and butter should be left to them as is a practice in several developing countries and that MNCs should play big brother’s role in marketing more important, newly discovered medicines. But the plea has fallen of deaf ears. The MNCs are, in fact, seriously interested in any, small or big, medicines which brings sizable profits. Their love for profits-though not immoral, not ignoble under the gospel of market capitalism which is inspired by them-is so ingrained that some of them do not mind even spices and dates. Another concern over the indifference of these pharmaceuticals to the local research and production of basic drugs. The multi-nationals are required to spend 1% of their profits annually on medical research and development of medicines from local raw materials, but they have contributed nothing since long, at least since 1979. This is a legal requirement. Under an agreement between the government and the MNCs, the latter undertook to make the contribution and in return were given certain facilities. One major facility they are blessed with is the adjustment of “transfer pricing” under which they charge exorbitant prices for the raw materials they import from parent office.

The difference between their price and the international market price is sometimes hundred times higher in their favour. So, before marketing a certain drug-a much higher, lucrative profit is already exacted and transferred to the parent office. This causes a heavy burden on the exchequer for the amount paid is in foreign exchange. But since this practice is done on legal grounds and to some extent on moral ones, and is prevalent the world over the losses thus suffered are not protested against by the host governments. But there are malpractices as well which the MNCs resort to particularly in methods on calculation in third world countries e.g. Pakistan where there is no check and balance. The government must incur blame for its failure to design a practical package of incentives which could induce basic manufacture by Pakistani companies or through joint ventures with the MNCs to promote an advanced chemical industry. In the past efforts to manufacture basic drugs, with a few exceptions, did not prove a success because of flawed policies. However, it is too important a matter to be left to bureaucratic whims because not for too long the country can afford huge import bill-both for raw material and finished products.

Pharmaceuticals are one of the worst sectors in the healthcare scene of Pakistan. It is the monopoly of a few giant pharmaceutical multinational brands that exploit the poor people of Pakistan and the present government is fully supporting this in the name of the sacred "free market economy". Soon after the deregulation of the industry by the Nawaz Sharif government the prices of drugs multiplied a hundred times. The multinationals are raking in as much as 500 times the actual cost of production of some medicines. The safe and tested drugs, which are on national and international essential drugs lists, are usually withdrawn from the market so that expensive alternatives can be sold. Many cheap life-saving drugs are constantly in short supply. The prices of some drugs are so high that even the middle class can’t afford decent antibiotics. Dangerous and irrational drugs that have been banned in the West are sold in Pakistan. Local doctors are misled by the pharmaceutical companies to prescribe junk drugs. And the government remains silent and allows this to go on so as not to offend the WTO and the icon of free trade".

During Ali Bhutto’s government this policy was analysed and the problem was identified. It was agreed that drugs must be cheap and affordable. In order to achieve this the Ministry of Health introduced the famous and radical Generic Drugs Ac {in the same Generic Drugs Scandal Surgeon Naseer Sheikh of the same Bhutto regime made billions} which was aimed at breaking the back of the multinational monopolies and actually managed to bring the prices down to a very low level. The problem with this reform, as with all the others, was that, as the capitalist system was not transformed completely, it was soon to be reversed. In spite of this even the subsequent government managed to maintain some degree of control over the prices. This, however, was lost when the Nawaz Sharif government signed the WTO free trade treaties. After the endorsement and introduction of the notorious T.R.I.P.S (trade and intellectual property rights) it has now become impossible to produce cheap generic drugs. The fate of the whole of the so-called Third World has been doomed by "free trade"!

SPURIOUS / COUNTERFEIT / BANNED DRUGS:

Another curse the Pakistani drug market suffers from is the presence of spurious, counterfeit and banned drugs in large number. According to the Burhanuddin Commission Report 1984, “Let there be no misunderstanding. Medicines and drugs once produced are not going to be dumped into the sea; they are going to be swallowed by the people whether they need them or not”. For example, some 40, 000 dextrose drips which were rejected the Public Sector Hospital in Karachi in 1987 after discovery of deadly organism in them, causing six deaths and returned to the supplies, reappeared elsewhere in the country and were sold in the open market. It is an irony that the medicines which are de-registered for some reasons are not publicly notified by the government, thus keeping the doctor and the people in dark about them, and the medicines concerned are thus ultimately sold and consumed. Regarding the production, marketing and dispensing of sub-standard medicines, such malpractices can be checked only if an effective monitoring system and quality control at the manufacture’s and exists. The monitoring by drug inspectors under the Drug Act is a farce. Needless to stress, the medicines cannot be treated as ordinary consumer items. These are the means to restoration of health to the people. Nor their prices can be left at the mercy of the manufacturers. Unless the buying capacity of the average Pakistani expands, the prices need to be tamed.

PRICE FACTOR:

It is generally accepted that the willingness to pay for any commodity or service is determined by the utility of this to the consumer. It has been argued that households, irrespective of their position in the framework of society, would be willing to pay for curative health care as without this in an emergency the cost to the family would be substantial, particularly in the case of the bread-winner, and that this would not be constrained by the affordable limits. However, if the user charge is greater than the affordability level of any household, then equity is said to have been violated. On the other hand, a user charge at the maximum level of the willingness to play places a considerable stress on the household in adjusting the basket of expenditure to cater for the specific service.

Many deaths in developing countries could be avoided if essential drug prices were lowered. The cost of medicines has a significant impact on healthcare in developing countries. Overwhelmingly, poor people in these countries pay for medicines out of their own pockets. They make enormous sacrifices to get treatment, sometimes at great financial risk to their families. One month’s course of fluconazole in Kenya, for example, costs more than an average year’s salary. But without it, cryptococcal meningitis and oral thrush are the painful fates awaiting many people infected with HIV. Reducing prices could mean extending a parent or income-earner’s life by a month, a year, or more. In the case of patient being cared for by a VSO doctor in Uganda, the extra time allowed her to finalize pension arrangements to guarantee financial security for her children. Some companies have started to lower prices in the past 18 months, which is a welcome development. But such price offers have not always brought the cost of medicines down to the lowest levels, nor is the range of drugs on offer best suited to meet each developing country’s healthcare needs.

A more systematic approach is needed, one that ensures low-cost supply to these countries and assures companies that lower priced products will not undermine their core markets. This places a special challenge on healthcare users in the UK and other wealthy countries. According to a National Opinion Poll commissioned by VSO last year, 87% of the general public feels that developing countries should pay lower prices for drugs to treat diseases such as HIV and AIDS. Now it is to the UK govt. and companies to respond. The companies, governments should be made accountable for their role in meeting the health needs of the majority of the world’s population, specifically the population of the poor countries. Assessment of the corporate social responsibility of pharmaceutical companies in developing countries should include demonstrable commitments against the following shenanigans:

Pricing:

The company should support calls for systematic, global approach to pricing overseen by an international public health body, to address the needs of developing countries. It policies should support substantial lowering of the price of medicines in developing countries, and it should publish a list of pricing offers made to developing countries, including details of any condition on offers. Price reductions should not be limited to one or two flagships drugs but should cover a range of products that are relevant to health priorities in developing countries.

Patents:

The company should refrain from enforcing patents in developing countries where this will exacerbate health problems, and should support lifting the agreement on Trade-Related Aspects of Intellectual Property (TRIPS) restrictions on the export of generic versions of patented medicines to developing countries where a patent is not in force, in line with the Doha Declaration. It should not lobby governments for stronger patent protection than that mandated by TRIPS, or for weaker public health safeguards. It should disclose to shareholders its lobbying position on patents and its expenditure on such lobbying.

Joint public private initiative:

The company’s approach to joint public private initiative (JPPIs) should be clearly stated as part of an overarching corporate social responsibility policy that addresses all issues surrounding access to medicines, including patent protection, pricing and R&D. The company’s JPPI’s should involve ongoing commitments to resolving targeted health problems as part of its long term business plan, and it should ensure that its JPPIs do not exclude vulnerable sectors of society. Its JPPIs should state objectives to integrate with, and strengthen, national health systems, and the company should report on their impact. It should also provide transparent information on its involvement in the governance of JPPIs including details of any conditions.

Research and development:

The company should publish target expenditure for its R&D on infectious disease and should support and participate in JPPIs that address such research. In developing countries, it should forego patent rights of drugs developed under such JPPIs, and its pricing policy should ensure that products developed as part of JPPIs are affordable to developing countries. Appropriate use of medicines The company should have a policy that supports and complies with the World Organization’s guidelines for good clinical practices for trials on pharmaceutical products. It should publish the full results of all clinical trials in a registry accessible to third parties. The company should have a policy that supports and complies with WHO ethical criteria for medicinal drug promotion and report to shareholders on complaints upheld.

AIDS/HIV AWARENESS:

The fact that HIV/AIDS is spreading because of lack of knowledge, denial, ignorance and poor access to health facilities was underlying the message at the South Asia Interfaith Consultation on Children, Young People and HIV/AIDS, held in Khatmandu, Nepal in 2003. The aim of this consultation was to provide a platform to various faith based leaders in this region so that they could discuss issues related to HIV/AIDS, share their experiences, and enhance role, responsibility and future actions of faith based communities in lation to prevention among children and young people, along with mitigating the impact of HIV/AIDS on those infected and affected. The need for combined efforts to help eradicate this menace was stressed.

Prevention is fundamental to defeating HIV/AIDS. Every person in every country must know how to avoid contracting and spreading the disease and should be empowered to act on this knowledge. To prevent infection through sexual intercourse one should follow the ABCs of prevention: ABSTINENCE (not having sexual relations); BEING FAITHFUL (having sexual relations with only mutually faithful uninfected partners); and if neither the first two conditions can be met it is important to use CONDOMS correctly and consistently. Blood transfusion should be made only when essential and one should ensure that the blood or blood products have tested negative for HIV. Similarly the spread of HIV through needles, syringes and cutting instruments can be prevented by avoiding injections whenever possible; not sharing needles and syringes; using only new, sterilized, disposable needles and syringes whether in immunization, health services or elsewhere, and sterilized surgical equipment.

An overwhelmingly negative attitude towards the disease and discrimination against women is an important factor in the spread of the disease. HIV/AIDS is also tied to economic, social and cultural conditions, values and practices that create a fertile breeding ground for the virus. The combination of poverty, social exclusion and gender inequalities make women and children more vulnerable to infection. Children and young people are at a greater risk as they are mostly victims of innocence. Conservative cultural values prevent young people from getting the accurate knowledge they need. Young people are not expected to discuss sex outside marriage. Religious leaders often feel reluctant to introduce the subject of HIV/AIDS to children or young adults and as a result the focus is only on the active adult population.

Children of parents affected by HIV/AIDS lose their family and identity, are left to fend for themselves, face psychological stress, have decreased opportunities for education, and are afflicted by increased malnutrition and loss of health. In order to protect themselves they should be empowered with knowledge and information on sexuality and sexual and reproductive health. This would enable them to understand how their body functions and make informed choices about their behaviour. Evidence shows that the more educated young people are about sexuality and responsible sexual behaviour, the better the chances are that they will delay having sexual relations or will properly protect themselves if they do.

They need knowledge about transmission, risks and prevention of HIV, and about the choices available to them, including the avoidance of sexual relations before marriage. The knowledge about voluntary and confidential counseling and testing for HIV, as well as care, support and treatment for those infected are also of vital importance. They should also be aware of the economic and social pressure that makes girls particularly vulnerable to unwanted and unsafe sex. For this they need skills and confidence to negotiate difficult situations, whether it is refusing unsafe or unwanted sex, or resisting peer pressure to use alcohol or drugs. Young adults need an environment that offers them a place within their faith community to talk openly and without fear of criticism about their feelings regarding HIV/AIDS, sexuality, death and other issues. They should have a voice and a meaningful role in community decision making and programmes, especially regarding HIV/AIDS prevention strategies for young people. In our part of the world AIDS is perceived as the disease of others, of people living on the margins of society whose lifestyles are considered perverted and sinful. The disease is seen as a sin and punishment from God. It has a strong association with prolonged illness, death, sex and drug use- issues that most of us find difficult to talk about openly.

It is important that people realize that AIDS is a disease like any other disease which can be prevented rather than looking at it as a retribution for one’s sin. Correct knowledge about the modes of transmission will help to remove the stigma. The people affected by HIV/AIDS need care and compassion rather than discrimination. Strict tenets around sexual behaviour, relationships and promiscuity, which are immediately associated with HI, prevent people from sharing their concerns, particularly their HIV status. This further leads to a sense of shame and fear amongst individuals, who might be in need of the support of faith, its leaders and its congregations. Religious leaders play an important role in the lives of people, particularly the masses. They are respected in their community, have an influence over the people who listen to them, and often seek their advice. Because of this religious leaders are in a unique position of being able to alter the course of the HIV/AIDS epidemic. They can shape social values, promote responsible behaviour that respects the dignity of all persons and protects the sanctity of life, and they can increase public knowledge and influence opinion.

They can also support enlightened attitudes, opinions, policies and laws in this regard; redirect charitable resources for spiritual and social care, raise new funds for prevention, care and support, and promote action from the grass roots up to the national level. Above all they can speak out against all forms of stigma and discrimination, and ensure care, compassion and support for all people infected and affected by HIV/AIDS. The tradition of serving those who are poor, sick and dying has been passed down for ages in all religions. Mosques, temples and churches are not only centres of worship; they are centres of learning, a nuclei of social activities and custodians of culture and tradition. In addition to meeting spiritual needs, they undertake many services, including religious education for children and youth, counseling, caring for the poor and the sick, with selfless support for people suffering from a multitude of serious and even
contagious illnesses. Due to this important and unique role in shaping social values and public opinion, attempts must be made to involve religious leaders in the fight against HIV/AIDS.

Religious leader can review spiritual writing, beliefs and tradition to support HIV/AIDS prevention and care. They can talk about the spiritual dimensions of Human Sexuality and about the need to protect others from harm, particularly young people who may be the victims of abuse, violence, exploitation, discrimination and trafficking. They can try to find ways to help people renew their duty to alleviate suffering, to affirm personal faith and to lead a life that fully respects the dignity and rights of others.

MENTAL ILLNESSES:

The determinants of a national priority vary from country to country. The inferences depend on the spectacles one uses. The health scenario focuses on economics and building of national character. Sound health plays a pivotal role in this regard and mental health is behaviour. Mental Health is unique in several ways. Most of the persons suffering from a mental health problems apparently “look well” except a handful except a handful who have had problems since early life. According to the WHO, 450 million people in the world currently suffer from, some form of mental or brain disorder, including alcohol and substance misuse. Within this huge number, 121 million people suffer from depression, and more than 800,000 people die of suicide each year, with young people accounting for well over half of these. Projections from 1990 to 2020 suggest that, in future, the proportion of the global burden of disease accounted for by mental and brain disorders will rise to fifteen%. There is a huge gap between “West” and “East”. The West is preoccupied with human rights, political correctness, development of new and expensive drugs, the rights of minorities, life skill, education, stigma, sophisticated technology, quality of life etc., whilst in the East, due to extreme poverty, various kinds of severe deprivations, chronic stress and diseases forgotten in the West (like for example, vitamin deficiency), people and professionals have other priorities like hunger, survival, ad hoc diagnostics, and traditional methods of living. Many countries of, the East are characterized by severe socio-economic deprivations despite availability of natural resources but otherwise flooded with war, conflicts, debts, and man-made disasters of various kinds at the expense of “Health Dollar”.

Mental Illnesses are among the first diseases to have been recognized as discrete illness, the oldest medical document in existence, the Eber Papyrus (probably composed in 1900 BC) contains references to specific syndromes such as depression. Biblical writings also contain references to Saul as failing into serious depression. Hippocrates related mental illness to brain and Galen and his followers believed that mental illnesses were due to imbalances in quantities of body fluids. Depression has been calculated as one of the costliest illness of the world. Of the ten leading causes of the world in persons between the age of 15 and 44 years, four relate to mental illness namely unipolar depression, alcohol use (in case of Pakistan drug/substance abuse), manic depressive (bipolar) illness, and schizophrenia. If one includes self inflicted injuries (i.e. Suicide), violence and infliction war and other manmade disasters, the morbid behaviour will exceed 75% of the shared cost to society.

Growing consensus on bio-psycho-social mode of diseases has evolved into the concept of holistic
medicine thereby incorporating all kinds of health professionals on one platform. The diseases can now be fought with people and professional together. Such a revolutionary change will require additional as well as re-allocation of resources. Investment in “Health” is invisible but highly rewarding. Neither govt. nor philanthropy alone can generate funds as the affordability criteria keeps on changing. Promotion of healthy lifestyle is both inexpensive and guaranteed form of primary prevention. Alternatively pharma industry will continue to bat on crease. “The success of our people in all walks of life depends upon the cultivation of “Sound Minds” the natural concomitant to “Sound Bodies”. {Late. Muhammad Al Jinnah}.

THE HAND THAT ROCK THE CRADLE:

Pakistan’s health problems have been considerable and women’s health problems even more so. Until recently, the entire focus of the country’s healthcare system was curative and tertiary care oriented, with little attention to primary health care. The combination of severe fiscal onstraints, political instability, lack of political will, discriminatory customs and traditions, growing inflationary trends and minimal attention to developmental needs have inevitably had a devastating impact on women’s health. The inverted sex ratio, prevalent in the South Asia region, still exists in Pakistan. The latest census (1998) while showing slight improvement over the previous 1981 census (111:100) still shows a sex ratio of 108:100. There is no national record or study to explain/identify the reasons for these missing girls and women - particularly pertinent given girls’ biological advantage at birth.

The consequences on women’s health and lives have been characteristic of other features of low development: high population growth rates, unending poverty cycles, and high levels of infant and maternal mortality. Anaemia and malnutrition in women, especially pregnant and lactating women, continue to remain unacceptably high, even according to government statistics. Generally around 45% women in the reproductive age group of 15- 49 years are anaemic. Pakistan's population is in the transitional phase of diseases, encountering both communicable and non-common diseases. Strong, concerted and sustained effort to achieve real change in women’s lives has not been apparent, with no policy direction, planning or clear-cut national mechanisms. During the 1990s, promises of land reform were unfulfilled and attention was diverted by distribution of small parcels of state land to poor land-less agriculturists. Despite vociferous demands from the women’s movement, women were never the beneficiaries and since the inputs to make such lands productive, such as water and credit were not provided, women could not benefit even indirectly, despite their continued toil. With the diversion from food to cash crops, food prices soared, which again hit women and children the hardest.

State patronage of traditional socio-cultural attitudes has created dichotomies in the nature of change necessary to meet the challenges of poverty, national development, and improvement in the status of women. There is resistance to creating a positive image of girls and women in the content of education and curricula, and textbooks continue to reflect patriarchal norms and values. Attempts to change the image of girls and women through interventions in existing textbooks have been only partially successful in the NWFP and to a lesser extent in Balochistan. In Punjab discussions have been held but no formal changes have been introduced in the textbooks. In Sindh, the exercise has yet to start. Issues pertaining to girls with disabilities have not been addressed. The development of gender sensitive learning materials developed by the government under the Punjab Middle Schooling Project is encouraging. NGO initiatives have focused on highlighting education as a basic human right and educating educators in women and child rights issues.

Failure of the state to respond to the widening gap between male and female perceptions of their roles is reflected in the increasing sexual harassment of girls and women as they move through public space to access educational and employment opportunities. With the exception of the NWFP, the media has played an ambivalent role in creating a favourable environment for promoting awareness about education and employment needs of women. Stereotyped images of women help reinforce the perspective that women should only receive training in fields related to traditional gender roles. Regrettably, despite the above advances, negative indications still exist: nowhere is the impact of inadequate health facilities and low status of women so stark as in the high rates of maternal illness and death. Pakistan’s maternal mortality rate continues to be amongst the highest in the world. It is estimated that for every woman who dies, approximately 16 survive with reproductive tract diseases, sometimes chronic and long drawn out. The worst among these are vaginal and rectal fistulae, mostly untreated due to lack of facilities. When combined with restrictive social norms, these can render women social outcasts.

In these circumstances, advocacy and implementation of the life-cycle approach, with improved healthcare and nutrition programmes for girls and women, promotion of ante and post-natal care, and enhanced provision of emergency obstetric care spell national challenges. It is noteworthy that all, except the life cycle approach, are identified in the above-cited RH package.
The need to incorporate gender equality and equity in all RH programms and services is imperative; but unfortunately, the RH package is focused towards provision of basic health/women’s health services, and Information, Education and Communication (IEC). It does not address gender equality. The programme also remains largely demographic and target-oriented, aimed at achieving lowered fertility rates, despite the Government’s endorsement of the ICPD-PoA which seeks to eliminate such target-setting, and particularly the targeting of women. For a large proportion of the population, even access to these services is not enough. Retrogressive customs and traditions still hold sway, hindering current efforts for progress. Legal provisions guaranteeing women’s reproductive rights are still conspicuous by their absence; their impact on women’s RH remains unrecognized. While specific actions to remedy this situation are included in CEDAW, the NatRep, PfA, and the NPA, and most importantly in the COIW Report, implementation is still absent. The wide-ranging attitudinal changes needed to rectify this situation have not been addressed, While there are Family Planning/Reproductive Health centres, negative traditions and customary practices, severely limiting women’s independent mobility, even in case of serious illness or the critical stage of high-risk pregnancy.

Reproductive Rights Issues

Six years after Cairo and five years after Beijing, national plans to ensure recognition of the integral link between the status of women and their RH have remained only partially addressed. A few positive steps taken in 1995-96 enhance this recognition were subsequently hindered by a lack of political commitment to addressing women’s reproductive rights’ concerns during 1997-99. Women continue to suffer from attitudes that violate their reproductive and other human rights, while discriminatory legislation further disempowers and marginalizes them. A specific illustration is that government and private clinics alike continue to demand written proof of the husband’s consent before married women can obtain tubal ligation, whereas a wife’s consent is not required for vasectomy. Abortion continues to be illegal (the only exception being in good faith to save the life of the woman or providing necessary treament to her), and this is particularly discriminatory and unjust in the case of rape, especially where unmarried girls/women are doubly victimized. The categorisation of rape and adultery as sub-sections of a single section, and the wide license given to law enforcing agencies, mean that women complaining of rape run the risk of being charged under adultery. The negative reproductive health consequences of increasing violence against women include physical and psychological trauma, clinical, emotional problems, and increased susceptibility to infection, including reproductive tract infections (RTIs), STDs and HIV/AIDS. These remain largely unacknowledged and thus unaddressed. Although no national statistics on domestic violence are available, sample survey reports indicate that incidence is high, affecting all socioeconomic strata of society. The pernicious impact of domestic violence/wife-battering/marital rape on women’s physical, reproductive and emotional health, and on non-permission for contraceptive use, are well-documented. Women with disability are especially vulnerable to violence and abuse, and are frequently unable to protect themselves (e.g. blind or mentally handicapped women being beaten or raped - both occur).

These severely violative and retrogressive trends threaten the comprehensive, progressive implementation of health programmes (or at best limit their benefits). In short, the strategic objectives of the PfA have only been partially addressed. A major obstacle in meeting all objectives is that while integration of services in the health and population sectors is in process, the contribution of the Ministry of Women’s Development (MoWD) remains the missing link. The recent merger of this Ministry with others has further diluted efforts for improvement of women’s healthcare, particularly RH and RR. In the Beijing +5 review, Balochistan, Sindh and Punjab identified the lack of political will and commitment, inadequate coordination between government and civil society, and mismanagement of resources as serious deficiencies. The GoP Social Action Programme (for education, health, rural water and sanitation, and population welfare) is meant to strengthen national developmental efforts and soften the impact of structural adjustment programmes. However, an independent study of SAP-1 by the Social and Policy Development Centre, showed little progress. Staff attendance was low; mechanisms to ensure implementation of safe motherhood programmes, treatment of RTIs and STDs, and prevention of unsafe abortions were insufficient. Review/assessment of SAP-2 has not taken place as yet. Also, given the simultaneous negative impact of structural adjustment programmes, it is difficult to assess the benefits of the Social Action Programme as a whole.

While there is no evidence of any decrease in the forms of VAW identified in the NatRep, there has been an alarming increase in violence and murder allegedly in the name of honour over the past years. Additional research and monitoring also resulted in bringing more information on the subject to public attention. Among other factors, this is indicative of a reformulation of the traditional discourse of honour as a means to justify the murder of women for social and economic reasons. Practices that were earlier confined to rural pockets in feudal and tribal belts have now spread to urban centres, indicating retrogressive social attitudes not only among the law enforcement agencies and the judiciary but also among the highest political decision-makers in the Senate and Assembly. After a particularly horrfic incident - the globally reported Samia Sarwar case - an opposition Senator introduced a resolution in the Senate condemning honour killings after a protest outside Parliament by women's rights activists. The resolution was signed by a significant number of persons from the Treasury bench as well as the opposition. It was therefore all the more shocking when, on 2nd August 1999, not only was the resolution thrown out, but Senators in their speeches also used abusive language about women and even supported the practice of 'honour' killings.

The failure to punish, even condemn, such behaviour encourages acts of violence against women. This happens both in instances where women attempt to exert their decision-making with regard to choice in marriage, mobility and/or work and in cases along more traditional patterns where women have served as scapegoats in male fights over property or other resources. In both instances the recourse to 'honour' and inherited lacunae in the law relating to bodily hurt and murder and the provisions for compromise (instituted since 1990) have led to a gross miscarriage of justice and at the same time provided a viable cover to criminal acts. Additionally, even though the clause ‘grave and sudden provocation’ reducing culpability no longer exists on the statutes, biased judgements are trying to resuscitate the provision. Every year scores of women are trafficked to Pakistan either to work in the local sex trade or to be sent on to the Middle East. These women are brought mainly from Bangladesh, India, Burma (via Bangladesh), and recently from the Central Asian states. It is important to distinguish between trafficking and illegal migration since there is substantial trafficking of women within the country, and trafficking cannot simply be defined as cross-border migration. The repatriation of Bangladeshi women is impeded by the Bangladesh Government requiring documentary proof of their origin. Trafficking of women is also a problem amongst the refugee community. (See Chapter E on Women and Armed Conflict) Prostitution is illegal, with laws making it easier to penalise the women engaged in prostitution rather than the brothel keepers/pimps, procurers and clients. Lengthy imprisonment terms combined with dual standards of sexual morality block rehabilitation of women caught in this trap. The illegal status of trafficked women makes it even more difficult to establish rehabilitation initiatives for them.

Women engaged in the sex trade are at high risk of STDs, HIV/AIDs and other health hazards but remain entirely ignorant of the threats posed by HIV/AIDs in particular. The official policy of ignoring this sector as non-existent impedes efforts for the safety of the women concerned. The area of VAW continues to be plagued by the existence of negative legislative provisions, and the negative attitude of police and judiciary. In addition is the non-compliance with positive specific rulings of the superior judiciary particularly on when cases should not be registered under the Hudood Ordinances and how to proceed when such cases are registered. Superior Court rulings directing branches of the administration, hospitals and the police to comply with standards and directives regarding procedures for medico-legal units have not been circulated or are being willfully ignored. There is also no internal monitoring and supervision to ensure compliance or to take action against police found to be violating these directives.

An amendment in Section 167 of the Criminal Procedure Code provides for women's safety with respect to the mode of arrest and detention of women by the police. But this provision cannot be effectively followed or implemented in the absence of necessary supporting initiatives, e.g. the training and gender-sensitization of the police or the induction of many more women in the police, that have not been carried out. The medico-legal units linking the police and hospitals are a serious continuing problem. The units are few and far between, the conditions for examination appalling and the attitudes of those in charge extremely insensitive and often hostile to women, especially victims of sexual abuse and/or domestic violence. They lack skills, equipment and orientation. They are also not complying with standard procedures. As a result, legal redress for women victims of violence is difficult and they often end up further traumatized by the experience of examination. On the positive side, the establishment of women's police stations and women police cells seems to have increased women's access to police (especially in the NWFP). In Sindh, the Woman Superintendent of Jail in Karachi has taken initiatives to improve the conditions of women prisoners and institute some programmes for rehabilitation. Unfortunately there is an appalling lack of data on the number of women currently in different jails, the nature of their crimes/cases and whether they are under trial, pre-trial or convicted. A proper database would facilitate the release of many women.

Violence at the Workplace

As more and more women enter the workplace, it has become increasingly important to consider the relationship between female and male employees, particularly as sexual intimidation by male co-workers has become more visible. Organizations in Pakistan, especially in the public sector, tend to perceive the idea of sexual harassment as a ‘Western plague’ that threatens to spoil ‘natural’ relations between men and women. Sexual harassment is rarely codified as a criminal offence. While private sector organizations have labor codes or human resource policies that mostly include only piecemeal stipulations that women can use to ensure a safe working environment, public sector policies have no safeguards against harassment at the workplace. Despite efforts by women’s organizations, no discussion has been initiated on policies or legislation that can assist women in combating harassment.

All forms of armed conflict make women more susceptible to physical and sexual violence, expose them to various forms of deprivation, and impact on their physical and psychological health both as direct and indirect victims. Therefore armed conflict is understood to encompass the situation of women during times of armed conflict of any kind - whether interstate or intra-state, religious, sectarian or ethnic, tribal or political armed conflicts. Unfortunately, and despite the presence of a large number of refugee women from Afghanistan and Kashmir and the continuing impact of armed conflicts within the country, this is an area where the level of activity on the part of the State and non-state actors has been extremely low in the past five years. In the meantime, the need for disarmament and peace has acquired new proportions following the 1998 nuclearization of the region, accompanied by a glorification of war and weapons of mass destruction and a militarization of state ideology. There has been increasing attention to gender baseddisparities in the health, nutrition and education status of girls in Pakistan, as well as to socio-cultural practices that reinforce the gender bias against girls and perpetuate discrimination.

However, given the overall vulnerability of children in Pakistan, and the socio-economic disadvantages facing women and girls, the situation of the girl-child calls for a renewed focus. Social conditioning projects girls as being of lower status, weak, vulnerable, dependent, subordinate to males, and in need of guidance and protection. Coupled with the inadequate educational system and negative media portrayal, this leads to girls having a low self-esteem, minimal awareness of their rights, very few opportunities and limited aspirations. Development planning for the girl-child is exacerbated by a lack of clarity on the age definition of the ‘girl-child’. The CRC defines a child as one below 18 years; the Majority Act in Pakistan defines those below 18 as minors. However, the minimum legal age for marriage is 16 for girls and 18 for boys. In child labour legislation, anyone below the age of 15 is defined as a ‘child’. Finally in some criminal matters (specifically sex-related crimes), females are defined as being adult at puberty, exposing the girl-child to criminal liabilities and severer punishments at an earlier age than boys.

The contradiction in definitions of adulthood under different laws deny the girl-child rights available to a boy of the same age.

Girl-Child and Early Marriages

Girls, especially in rural areas, tend to attain puberty at ages ranging from 9-12 years. Data gathered by demographers over the past decade shows a steadily rising age at marriage even for girls. Other sociological and anthropological research, however, points to a continuation of the cultural norm of early marriage, especially in rural areas (where 68% of Pakistan’s population resides), and the presence of 12-14 year old girls who are either pregnant or already mothers. To circumvent the law, parents record their daughters’ age as 16 in the marriage certificate (a legally required document). Since a birth certificate is not yet a legal requirement for marriage in Pakistan, there is no way to check falsification of age on the marriage contract.

Early marriage has serious implications for girls’ reproductive health, especially when added to low literacy levels, inadequate access to basic reproductive health services (BRH), information and counseling. Adolescent girls enter the vicious cycle of too early, too frequent and too many high-risk pregnancies, resulting in morbidity, child-birth complications and maternal mortality. This robs the child of her childhood, the right to play and recreation, the right to knowledge of options and choices – in short the right to recognition as a human individual in her own right.

Child Labour

Various initiatives on child labour issues focus on rehabilitation and providing access to both formal and non-formal educational opportunities. While these are not girl-child specific, they do reach low income urban and peri-urban girls in selected locations. There is now a need to take such worthwhile initiatives to scale, and, more important for the Government to take over ownership for long-term sustainability. A positive step in this direction is the Government’s recognition of the issue of child labour, and specifically girls within this. Such initiatives have far-reaching consequences in terms of impact on future generations. By increasing awareness, they also supplement and strengthen other initiatives that focus on reducing gender disparities in BRH, nutrition and education. Foremost in this is the Social Action Programme, (SAP), which has achieved considerable success in these sectors, especially education, through the increased enrolment of girls in primary schools, as well as non-formal education centres, in which NGOs also participate.

Child Domestic Labour:

An issue that has consistently been ignored in development planning/programming, is that of child domestic labour. The category of domestic servants is not covered under any of the labour laws, thereby exposing domestic servants to all forms of abuse. Sexual abuse and exploitation is also a common problem for child domestic workers, particularly girl servants, along with economic exploitation, a fact substantiated by findings from several research studies that analyzed the psycho-social environment of child domestic servants and its impact on them.

Child Abuse

There has been an alarming increase in the incidence of child sexual abuse in Pakistan. While this includes both boys and girls, unfortunately, it is the latter who suffer greater atrocities. Violence and sexual abuse continue to play a strong role in disempowering the girl-child. Despite strict penalties for rape and gang rape, and processing gang rape cases in the specially constituted Anti Terrorist Courts, lacunae in the law combined with the attitude of law-enforcing agencies, discourages the registration and prosecution of such cases. While stringent laws were formulated for rape and child sexual abuse, including the amendment in the Hadood Ordinance to award the death penalty to convicts of gang rape, the intricacies involved in the problems of reporting child sexual abuse and rape remain unaddressed. NGOs feel that capital punishment cannot served as a deterrent to these heinous crimes if the prime focus does not go beyond this to emphasize restructuring of the system of redress.

Studies have also been conducted on the sexual abuse of the girl-child. Importantly, a donor-sponsored study on child sexual abuse in NWFP was officially recognized by the Provincial Government. Adopting the life-cycle approach has had a major impact on refocusing development efforts on the girlchild in the health sector. Initiatives range from addressing the communication gap between mothers and daughters on issues surrounding puberty, to greater awareness of the nutritional needs of the girl-child (‘tomorrow’s mother’). Hitherto taboo subjects such as sexuality and reproductive health are being taken up by NGOs, and moreover, are being received positively by communities. While these NGO initiatives have major implications for healthier mothers and babies in the future, they are catalytic, and need to be taken to scale for a broader impact at a national level.

BAD ECONOMY MEANS RUINED SOCIAL SECTOR (READ HEALTH).

GDP:

Purchasing Power Parity- $ 311 Billion.

Real Growth Rate- 4.5%.

Per Capita: Purchasing Power Parity- $ 2,100.

GDP Composition by Sector:

Agriculture: 24%

Industry: 24%

Service: 51%

Population Below Poverty Line:

35%

HOUSEHOLD INCOME OR CONSUMPTION BY PERCENTAGE SHARE:

Lowest 10%: 4.1%

Highest 10%: 27.6%

DISTRIBUTION OF FAMILY INCOME :

41.

INFLATION RATE {Consumer Prices}:

3.9%

UNEMPLOYMENT RATE:

7.8% Plus Substantial Underemployment.

BUDGET:

Revenue: $ 12.6 Billion

Expenditure: $ 14.8 Billion

DEBT EXTERNAL:

$ 32.3 Billion

ECONOMIC AID RECIPIENT:

$ 2.4 Billion

DISMAL ECONOMY:

Pakistan, an impoverished and underdeveloped country, suffers from internal politically disputes, low levels of foreign investment, and a costly, ongoing confrontation with neighboring India. Pakistan’s economic prospects, although still marred by poor human development indicators, continued to improve in 2002 following unprecedented inflows of Foreign Exchange Reserves have grown to record levels, supported by fast growth in recorded worker remittance. Trade levels rebounded after a sharp decline in late 2001. The government has made significant inroads in macroeconomics reform since 2000 but these are all tall claims as majority of the population living under back breaking poverty and no benefit of much talked about International Aid has trickled down to the common man. Although it is in the second year of its $ 1.3 Billion IMF POVERTY REDUCTION AND GROWTH FACILITY, Pakistan continues to require waivers for politically suicidal reforms. Long terms prospects remain uncertain as development spending remain low, regional tensions remain high, and political upheaval weakens Pakistan’s commitment to hinge on Corps Performance dependence on foreign oil leaves the import bill vulnerable to fluctuating oil prices; and efforts to open and modernize the economy remain uneven. One of the key themes identified was globalization and its attendant Structural Adjustment Programmes (started in Pakistan in 1988). Together with an increasing national debt, loans and conditionalities, the roll back of the state and push towards privatization, these have had a major impact on the local economy and on Social (can be read as Health) through increased poverty and the erosion of safety nets. The contradictory policies of international financial institutions, and to a lesser extent, those of bilateral and multilateral agencies, contributed to the problem.

The same institutions supporting or implementing social reform programmes also had agreements with the Government of Pakistan introducing conditionalities that are unhelpful, or that actually undermine the ability of people to cope with negative developments. These further marginalise the Social development (read health). Existing global economic structures and the New World Order continue and intensify the depletion of natural resources through unsustainable development policies. Globalization has also led to financial and human mismanagement of available national resources and a mismatch between indigenous needs and allocations as well as a brain drain out of the country. There was also concern at the donordriven
nature and/or dependency of many, if not all, of the initiatives for women. These are therefore resisted by government/state implementors and also not sustainable beyond the support cycle.

They are further disadvantaged by being generally perceived as part of the "western", "donor" agenda, incompatible with religio-cultural social norms and traditions, and, thereby, unworthy of GoP ownership and commitment. At the national level, globalization entails a roll back of the state in certain sectors. The abdication of the state from its primary responsibilities of providing for the basic needs of and security of its citizens is furthered by imposed policies which call for (a) the privatization of social sector services such as water and health, and (b) the removal of protective social sector measures (e.g. subsidies ensuring food security). In Pakistan, the situation is made worse by a highly centralized administrative and taxation system, the concentration of power and resources in the hands of a small minority, and bureaucratic hurdles
that impede institutionalization of efforts. Indeed Pakistan is witnessing erosion of state institutions and their capacity. Additionally, efforts promoting women’s empowerment have to contend with frequent political changes that negatively impact on policies and interventions and an ad-hocism in planning and implementation that prevent continuity.

Cont/P-7