Daily Times

Both Pakistan’s current health policy framework and its implementation is a far cry from the goal of universal health coverage. Every citizen should have access to health care but that is not the case. The consequence of the sparse and low-quality services provided by the public sector means that most people in Pakistan rely on private healthcare. In the absence of a state-supported health financing system, payments for private services being inevitably out-of-pocket and expensive, affordable quality healthcare is effectively beyond the reach of large swathes of the population. An injury or disease can be all it takes to plunge a middle or low-income household into debt and deep poverty. For those already below the poverty line, sickness can deplete resources entirely. As a result, poor people often live with chronic morbidities and face higher rates of mortality. WHO estimates that about 100 million people are pushed into extreme poverty every year because of out-of-pocket spending on healthcare. Many of them are likely to be from Pakistan.

The health system has been devolved to the eight federal units (provinces and administrative areas) through the 18th Constitutional Amendment of 2010, whereby strategic planning also became a provincial responsibility. That is a bit of a problem because health care system needs to have the same structure in all of Pakistan. The health system is a public-private mixed system of a large government infrastructure of primary and secondary health facilities in rural and peri-urban areas, and large teaching hospitals in urban areas. An extensive private medical sector is widely used and consulted. Primary health care services are provided through over 7500 first level care facilities and outreach services in the public sector. More than 100 000 lady health workers supposedly to provide primary health care services at the doorstep for rural and slum urban areas. On paper, this is an elaborate government-administered system designed to serve people free of cost through a multi-tiered and inter-linked network. The reality is that this system of government-provided healthcare does not work. At the lower levels, Basic Health Units and Rural Health Centers are barely functional. Poorly equipped and understaffed, and many of these health centres are in fact ‘ghost facilities’. The staff salaries are low and paid irregularly. Same with lady health workers. Mosques and religious persons are sowing doubt in the minds of uneducated and superstitious people and religious militants are threatening lady health workers who try to promote birth control measures and vaccination against polio and other diseases.

There needs to be a Centre for Disease Control and Prevention (CDC) that works as the nation’s leading public health agency, dedicated to saving lives and protecting the health of Pakistanis

Pakistan has well-equipped private hospitals and good doctors many of them with education from abroad. In this highest category of private health care one can get all the latest treatments in Pakistan – it’s just a matter of money. Pakistan itself provides a rather good medical education in the old medical colleges, those Pakistani doctors prove their worth everywhere in the world. But that is one of the problems: many doctors leave the country for greener pastures, running away from miserable working conditions, inadequate pay and corruption in the service structure. This brain drain has to be stopped and revised which means that first the problems in the domestic health care system have to be solved. Lately a number of private medical colleges with substandard education producing substandard doctors has come up; these need to be closed. Only one medical board for all Pakistan must ensure exams to ensure quality of medical education. Education of nurses and medico-technical staff (CT, laser others) has to be widened and improved. In many hospitals sophisticated equipment is rotting away because nobody can handle it or repair it and find spare parts. Pakistan believes in alternative medicine and indigenous health care methods like “Unani”. They have to be visibly separated from the school medicine for the people. Quacks, so-called doctors without a valid education or miracle healers need to be prohibited from practising.

Public health is the science of protecting and improving the health of people and their communities. This work is achieved by promoting healthy lifestyles, researching disease and injury prevention, and detecting, preventing and responding to infectious diseases. Much of that work has to be done in schools and in private homes or in community centers by health workers. Public health professionals try to prevent problems from happening or recurring through implementing educational programs, recommending policies, administering services and conducting research-in contrast to clinical professionals like doctors and nurses, who focus primarily on treating individuals after they become sick or injured. Public health also works to limit health disparities. A large part of public health is promoting healthcare equity, quality and accessibility. It includes information about vaccination, prevention of diseases, cleanliness. Most of the work of public health workers is preventive. Some of the education and information about prevention could be done via TV channels, media campaigns and on social media. That means the education of public health workers – ladies or gents- has to be upgraded.

There needs to be a Centre for Disease Control and Prevention (CDC) that works as the nation’s leading public health agency, dedicated to saving lives and protecting the health of Pakistanis. CDC works by controlling disease outbreaks; making sure food and water are safe; helping people avoid leading causes of death such as heart disease, cancer, stroke and diabetes; and working globally to reduce threats to the nation’s health. When a national health security threat appears, CDC may not know right away why or how many people are affected, but the agency has close contact to WHO to fight public health hazards. Ideally it should exist at the national level and have guiding competence for all provinces. The CDC could also coordinate epidemic research and coordinate with Disaster Management

Beyond piecemeal measures, governments in Pakistan have made no systematic efforts to overhaul a failed system. Public-private partnerships have been initiated in some districts to fix dilapidated public hospitals. Attempts to introduce government-supported health insurance through the Prime Minister’s National Health Programme in 2016 and the Sehat Sahulat programme of the PTI government have not been consistently implemented. The “National Health Vision 2016-2025 for Coordinated Priority Actions to Address Challenges of Reproductive, Maternal, Newborn, Child, Adolescent Health and Nutrition” published in 2016 highlights ten points how to create and reform a reproductive health system for Pakistan. A streamlined national health policy for all other parts of healthcare is needed and its implementation has to be monitored despite 18th Amendment having devolved health to the provinces.

Access to and affordability of essential medicines are integral to universal health coverage, particularly as a large part of out of pocket and public expenditures is on medicines. The health system faces challenges of verticalized service delivery and low performance accountability within the government, creating efficiency and quality issues. The public sector is inadequately staffed and job satisfaction and work environment need improvement. The overall health sector also faces an imbalance in the number, skill mix and deployment of health workforce, and inadequate resource allocation across different levels of health care

Mr Ikram Sehgal is a defence and security analyst while Dr Bettina Robotka, former Professor of South Asian Studies, Humboldt University, Berlin)