Daily Times

The Covid-19 global pandemic has affected the lives of billions, with more than 100 millions children; parents and guardians have lost jobs and movement restricted with sealed borders. According to UN estimates, global economy could shrink by 1 percent instead of growing at 2.5 percent in 2020. While this has short run as well as long run effect on the public health infrastructure, well-being, and human development – 40 percent of world population does not have access to hand washing facilities with clean water and soap at home. Making things worse, 16 percent of healthcare facilities do not have hygiene facilities. Almost half of the world’s children are affected by school closures in around 120 countries. Millions live in cramped conditions making physical distancing almost impossible. Hence, all the more reasons today, for us to revisit public healthcare architecture in Pakistan.

For the most vulnerable groups, longer inaccessibility to healthcare services means chronic nutrition challenges in mother and child, compromised immunization coverage, susceptibility to killer diseases and lack of accurate data. In previous health emergencies, the world witnessed that these vulnerable groups are at high risk of exploitation, abuse and violence. Figures show that during Ebola outbreak in West Africa in 2014-2016, spikes in child labor, sexual abuse, rape and teenage pregnancies were at a record high in the region.

While global health systems struggle to fight the current pandemic, we cannot save one person from Covid-19 and then lose many to other deadly diseases. As the famous saying goes, “never let a (good) crisis go to waste” – it is time for governments to rethink public health models, to reprioritizes health resources and enhance health system productivity. Policy makers around the world are increasingly relying on future health financing scenarios to identify gaps for sufficient funding and ensure accurate amount of services is provided.

Through incremental healthcare funding, universal healthcare access and coverage for the poor and vulnerable, channelize resources for sustainable population growth, build evidence-base and upgrade disease surveillance systems

Health systems are relied upon to serve population needs in an effective and equitable manner. Factors determining public health structures may be gauged in various contexts of physical infrastructure, wealth distribution, poverty, socio-demographic dynamics, level of education, cultural and religious beliefs, environmental conditions, disease pattern, mortality rates, gender discrimination and political topology.

For Pakistan, the country simultaneously faces double burden of disease; high prevalent communicable, maternal, childhood, nutritional disorders and non-communicable diseases. With current resources diverted towards fighting Covid-19, already weak health infrastructure and fragile socio-economic indicators are showing widening cracks that require urgent and long overhaul. Public health narrative is reduced to lip service with political parties that have pleaded structural changes. While successive governments have vowed to renew and strengthen primary and secondary healthcare system, fact remains that public health spending has been less than 1% of GDP for over decades (0.97% in 2018).

In 2018, Pakistan ranked at 150 out of 189 countries at the Human Development Index. While some might argue that slight improvement has been witnessed; in 2012-13, 45 percent of children were stunted which dropped to 38 percent in 2017-18. Wasting in children declined from 11 percent to 7 percent, while the prevalence of underweight children declined from 30 percent to 23 percent. Childhood mortality rates have declined since 1990. Infant mortality has decreased from 86 deaths per 1,000 live births in 1990 to 61.2 deaths in 2017 – compared to 38 in India and 8 in Sri Lanka in 2017. According to the Economic Survey of Pakistan 2018-19, under 5 mortality has noticeably declined from 112 to 74 deaths per 1,000 live births. Life expectancy in Pakistan for women is 67 years, as compared to 73 in Bangladesh and 78 in Thailand. The maternal mortality rate in Pakistan is 170 per 100,000 live births, in contrast to 30 in Sri Lanka and 20 in Thailand.

Cumulative health expenditures by federal and provincial governments during 2018-19 (Jul-Mar) increased to Rs. 203.74 billion; 3.29 percent higher than corresponding period of previous year, recorded at Rs. 197.25 billion. The current expenditure increased by 19.84 percent from Rs. 149.97 billion to Rs. 179.72 billion while that of development expenditure decreased by 49.19 percent from Rs. 47.28 billion to Rs 24.03 billion.

However, distribution of expenditures among federal and provincial governments demonstrate that during July-March FY2019, Federal and Punjab health expenditures decreased by 10 and 8.2 percent, respectively, over same period last year. On the other hand, Sindh, Baluchistan and Khyber Pakhtunkhwa health expenditures increased by 22.2, 18.4 and 10.5 percent, respectively. As percentage of GDP health expenditure has improved from 0.91 percent in 2016-17 to 0.97 percent in 2017-18 and during FY 2018-19 (Jul-Mar) it increased by 0.53 percent compared to 0.49 percent during corresponding period last year. But, given our public health needs, growing population and health inequalities, are these allocations enough? Given the mammoth problem, national health response is repeatedly under-resourced and unsustainable leading to long-term imbalance between disease burden and efficiently allocated health expenditure.

While vertical public health programmes have been devolved to the provinces, by 2018, the number of public sector hospitals was 1,279, 5,527 Basic Health Units (BHUs), 686 Rural Health Centers (RHCs) and 5,671 dispensaries. These facilities together with 220,829 registered doctors, 22,595 registered dentists and 108,474 registered nurses bring the current ratio of one doctor for 963 persons, 9,413 persons per dentist and availability of one hospital bed for 1,608 person. In Karachi, a city of 20 million people, there are only a total of 600 beds in intensive care wards. The World Health Organization (WHO) recommends a 50:1 ratio of general wards to ICU beds, with trained nurse for each bed in the ICU. Number of ICU beds in twelve major tertiary care hospitals in the largest province Punjab adds up to only 250. One of the largest hospitals of the Punjab, Jinnah Hospital, has 34 ICU beds out of a capacity of 1250 beds. In addition, there is only one nurse available to serve 2000 people in Pakistan.

With annual budget 2020-21 around the corner, successive and sustained increments in public health financing are critical. Given our slow economic growth rate, and dismal budgetary allocations, it might be decades before achieving desired preparedness to address public health crisis. While constitutional arrangement ensures fiscal governance and administrative organization to empower provinces, the onus lies with the federal government to lead. Equally important is to develop strong horizontal and vertical coordination structures (amid Federal and provincial governments) between finance, health, and other stakeholders to address health inequalities and gaps in service delivery. Simultaneously, it is critical to introduce accelerated reform that ensures spending efficiency and system-absorption capacity to maximize efficient disbursement. Through incremental healthcare funding, universal healthcare access and coverage for the poor and vulnerable, channelize resources for sustainable population growth, build evidence-base and upgrade disease surveillance systems. This would also require fixing the local government quagmire that the country faces. Effective district health system provides a silver lining here: improved health service delivery and fairness in financial distribution.

In the words of Middle Eastern historian Yuval Noah Harari, “When choosing between alternatives, we should ask ourselves not only how to overcome the immediate threat, but also what kind of world we will inhabit once the storm passes.” Our every decisions today impacts post-covid world for future generations.

Technical Advisor – National Parliamentary Task Force on Sustainable Development Goals