A sick system

The existing public healthcare systems in Southasian countries are largely the legacy of colonial administration. Despite the fact that these systems are now worn dangerously thin, they remain little changed. With the limited resources at their disposal, regional public health focuses almost exclusively on the urban sector, neglecting the rural majority. The system in place in Pakistan is no exception. The average family here is large, its members lack education, and are undernourished and unhealthy. At the moment, the Islamabad government is doing almost nothing to change this situation. In a region plagued by poverty, pollution and rampant disease, with enormous rural populations largely neglected by their respective states, Southasian governments have begun to realise that a healthy economy is impossible without a healthy people. A lack of attention to public health amounts to condemning a large section of the population to difficult, short and unproductive lives. This does not help in the creation of an educated, skilled and competent middle-class workforce, which is essential for the development of a market. Records of Pakistan's recent economic performance show marginal improvements in the manufacturing sector, but economic progress will remain low as long as its social indicators remain dismal. With the exception of war-torn Afghanistan and Nepal, Pakistan's vital health statistics are currently lower than that of every other Southasian country. Despite the grim scenario, Pakistan's health sector remains a low priority for its government today, conspicuously so when compared to the country's notoriously well-funded military sector. In recent years, health and education have seen only token increases in allocations. In order to more fully explore the effects of this neglect, professor K Zaki Hasan, the founding dean of two Pakistani medical institutions, has compiled in Public Health Challenges in Pakistan a body of statistics that speaks for itself. Total public and private health expenditure in Pakistan accounts for just 2-3 percent of the country's gross domestic product. In 2001, less than one percent of the GDP was allocated for public healthcare, whereas expenditure on debt servicing and defence exceeded the country's total revenue. Pakistan's total health expenditure per capita was only USD 13 for 2005, having declined from USD 16 in 1998. In comparison, in Sri Lanka that amount is USD 32, and in the Maldives it is USD 120. Indeed, Pakistan's vital statistics for health are low even within a region where such statistics are generally poor. Although 2004 figures show that the country's life expectancy has increased to 61 years from 43 years in 1960, this is still an excruciatingly low national average – regionally, Pakistan fares better than only Nepal and Afghanistan in this regard. Infant mortality rates are very high, at 81 per 1000 live births as of 2003, as per UNICEF figures from 2004; in Nepal that figure stands at 61, and in Sri Lanka at 13. Mortality rates for children under the age of five are 103 per 1000 live births, as per UNICEF's 2005 figures, again high for the region. Malnutrition is the reason for half of these deaths. To complete this sorry picture, maternal mortality rates are 500 per 100,000 live births, with only 20 percent of children being delivered by trained medical personnel. Dr Hasan, who has been working closely with the Islamabad government since 1970 in shaping the country's public-health policies, offers the reader a perspective on the health sector from within the administration. He also brings to the text a social-scientific approach that tries to get at the deeper causes of Pakistan's health-sector ills. Problems in the country's healthcare are not simply a matter of inadequate funds. Instead, Hasan places a significant amount of the blame on a culture of patriarchy and the low status of women, which in turn manifests itself in low female literacy rates and female disempowerment. The combination of inadequate primary healthcare and high population growth leads to a significant prevalence of communicable disease, especially among children. Government figures for 2004 also show that manpower imbalances persist, as Pakistan's nearly 108,100 doctors – highly concentrated in urban areas, and showing marked preference for work in private hospitals – far outstrip a countrywide nursing staff of just over 46,300. Recruitment in the medical and public health sectors is also dangerously skewed in favour of men. The lack of decentralisation in Pakistan means that government hospitals are found almost exclusively in urban areas, even though most of the population lives in the countryside. The majority of Pakistanis thus have little access to hospital beds or doctors, and must either travel long distances for medical treatment, or rely on practitioners of traditional medicine. Pakistan's urban rich, able to afford private treatment, are oblivious to the country's healthcare pinch. The rural poor, on the other hand, comprise 90 percent of the population. It is imperative that medical manpower be developed for the rural public-health sector. Hasan also points out that close attention needs to be paid to the country's environment, with an eye to the growing population. The bulk of health problems in Pakistan are comprised of respiratory infections and diseases such as cholera, typhoid, dysentery and hepatitis, most of which affect children. These are brought on largely by systemic problems such as biological contamination in water, industrial waste and air pollution. Inadequate attention is not exclusive to children's health, and Hasan also stresses that both women's health and mental health are in need of increased consideration. Grassroots knowledge
Islamabad came up with two innovative social-action plans in recent years, in 1991 and 1996, spanning five years each. Both offered broad goals of upgrading primary health, primary education, public welfare and rural water supply and sanitation, and were expected to significantly accelerate improvement in the health sector. Supported by the World Bank and involving both government and NGOs, the participatory development model encouraged people to initiate projects to improve social services in their own communities. Unfortunately, the scheme failed to meet its goals and was finally disbanded. Insufficient funds were cited as one reason for the failure, as were politicised and lopsided disbursement policies. Provincial governments with high budget deficits could not afford the long-term expenditure required by the projects, and neither could they generate revenue to finance them on their own. To make matters worse, by the end of the second phase in 2001, the plan had in fact decreased expenditure on basic services from the allotted 1.7 percent of GDP in the base year of 1991-92 to 1.4 percent during 1999-2000. Islamabad's experiments with such social-action plans present a classic example of unrealistic approaches to problems concerning large populations. Particularly in situations where funding is a problem, it would make more sense to implement policy changes at a grassroots level, and subsequently let them work their way up to the top. When government officials work with local organisations that have direct access to people at a local level, even small budgets can prompt significant effects. Though public-health policy is changing in Pakistan, this is happening much too slowly. It is not acceptable to allow the system to gear itself over the next decade to tackle the problems it faces today. Pakistan's population is growing, and so are the numbers of poor and ill – the much-touted benefits of globalisation notwithstanding. Increased numbers will continue to strain a system that has not reformed itself quickly enough or with adequate foresight. Pakistan's primary healthcare system urgently needs to be overhauled. A strong network must be created in place of the existing system, under which a basic but well-equipped medical unit is created in every village. Literacy programmes are needed, as are awareness programmes to educate people about the sources and dangers of various diseases. In this regard, a UNICEF project in West Bengal offers an important lesson. After months of trying in vain to explain to villagers why they should not drink water straight from local ponds, government doctors set up a microscope one day in the village commons. Each villager subsequently looked through the lens to see the microbes squirming in the untreated pond water. Within six months, cases of waterborne diseases in the village had been nearly halved. What works in rural West Bengal, surely may work in rural Pakistan. In the preface to Public Health Challenges in Pakistan, Dr Mubashir Hasan states that, "a modern nation state is contractually bound to do the very best it can to look after the health of its citizens." The Islamabad government would now do well to remember this. It is imperative that it muster the political will to understand the vast and complex spectrum of causes that affect collective well being, and to act on that knowledge with speed and intelligence.