Daily Times

The 74th birthday party of the World Health Organization (WHO) fell on April 7. As we observed this day, with the theme ‘Our Planet, Our Health’, it afforded us an opportunity to deliberate on the state of Health in Pakistan. For over two years, we have been afflicted by the COVID-19 pandemic. Whether it is a coincidence or otherwise, such pandemics come once in a century and serve as a warning for those of us in public health, and to humanity at large, to do a better job and be better prepared for the next one.

After retiring from WHO and graduating in public administration, I met the Chief Medical Officer of the Kansas University Medical Center, USA in May 2017. As our conversation progressed, he showed me that week’s issue of the Time magazine with the cover story entitled – “Warning: We are not ready for the next pandemic.” During our conversation, we both endorsed the contents of the cover story for a plethora of reasons. Less than five years later, the COVID-19 virus struck our planet with full force.

Pakistan is in the 75th year of its existence, yet we lack clarity in deciding what the federal or provincial governments should be doing for health. On Independence in August 1947, Health was regarded as a provincial responsibility or subject, yet Raja Ghazanfar Ali Khan was there in our first cabinet of no more than 7 persons holding the portfolio of Health. With a few exceptions, healthcare services delivery has always remained a provincial domain, while policymaking was regarded as a joint responsibility of central and provincial governments. So, things continued until the first truly democratic parliament elected on the basis of adult franchise unanimously adopted a federal Constitution of the Islamic Republic of Pakistan, as the supreme law, on April 10, 1973, and made it effective from August 14, 1973.

At that time, it was decided that not just Health, but all the Social Sectors, would be provincial responsibilities. However, on the request of certain provinces requiring continued federal support until they could independently manage this added myriad of responsibilities, a concurrent list was added to the constitution comprising both federal and provincial subjects including Health, for a period of 12 years till 1985.

Earlier in 1972, the People’s Health Policy had been announced, which entailed a broader coverage of health facilities across the country to make them more accessible to the rural masses. Some elements of the policy including the generic drugs scheme found their way into the Alma Ata Declaration in 1978 calling for Health-for-All by the year 2000 using the Primary Health Care (PHC) methodology. PHC is more a philosophy or approach than a level of care.

The constitution has remained in force for nearly half a century although there were around 20 years of direct military rule during which some provisions of the Constitution were kept in abeyance, while several amendments were made to suit dictators. The 18th Constitutional Amendment impinged on more than 100 articles of the constitution of Pakistan to reverse many infringements made in the Constitution by non-democratic rulers over decades. It was given assent by the President of Pakistan on April 19, 2010, after its approval by the parliament to restore the democratic character of the supreme law of the land.

The amendment granted provinces greater autonomy and decision-making power in many sectors including Health. The functions included in the Concurrent List were removed leading to the outright abolition of the Federal Ministry of Health. At that time, it was almost a certainty that around 18 ministries or divisions would be wrapped up leaving the Federal Government with only five subjects namely finance, economic affairs, defence, foreign affairs, communications, and central revenues by the cut-off date of June 30, 2011.

In hindsight, it seems that after the enactment of this constitutional amendment, all stakeholders should have actively worked towards building provincial capacities in the 15-months interval available. Instead, the federal government appears to have been in denial. On June 29, 2011, the Federal Minister for Health declared that the Federal Ministry of Health would not be devolved, nevertheless the same night it was wound up along with seventeen other ministries or divisions including education, environment, population planning, food and agriculture, sports, women development, minorities’ affairs, labour and manpower, social welfare, tourism, and culture.

Thus, in effect what had to be done in 12 years following the 1973 constitution, actually materialised after 38 years, but without a day’s preparation. It is also debatable whether the original authors of the constitution envisaged such a drastic move at all, as Pakistan emerged as the only country in the world without a Ministry of Health, which existed even when we achieved Independence.

The dissolution of the Ministry of Health was followed by total confusion and fragmentation of the federal health functions within the Planning Commission, Cabinet Division, National Regulation and Services Division, Economic Affairs Division, Inter-Provincial Coordination Division, States and Frontier Regions Division, Capital and Development Division and the Federal Bureau of Statistics. All the national programs for reproductive health, nutrition, population welfare and communicable disease control were also abolished creating difficulties not only for the government but for its development partners as well. After a few months, the program implementation units for the control of TB, HIV/AIDS, Malaria, and vaccine-preventable childhood illnesses (EPI) were restored to validate agreements with The Global Fund and GAVI.

During the period of the caretaker government, on May 5, 2013, all vital federal health functions were transferred to a newly created National Health Services, Regulation and Coordination Division, which was subsequently upgraded to a ministry. The national responsibilities for health in federal systems mostly include evaluation of health information, international health regulations, regulation of education of all health cadres, regulatory measures for drugs/medicines, dealing with development partners, honouring international commitments, trade-in health, establishing uniform policy norms and standards, and interprovincial policy coordination. The reorganization decision on the federal health sector governance accomplished by the caretaker government was quite commendable, however, almost ten years down the line, confusion yet persists due to the initial setbacks.

Pakistan has unenviable health and demographic indicators and inadequate coordination, between the federal, provincial and district tiers may give rise to inefficient use of human and financial resources, lack of proper accountability and sub-optimal outcomes. Health financing issues also crop up at the provincial level as the federal government provides lumpsum monies to the provinces, leaving it to their discretion how much to apportion for health. Therefore, despite enhanced resource provision, health allocations may not increase appreciably, although the overall health financing in the country has generally improved.

More importantly, Pakistan has to attain Universal Health Coverage, which is the crucial element of Sustainable Development Goal # 3, and it is imperative that all provinces make coordinated efforts to reach the requisite targets, which cannot be achieved with the current pace of the effort. Non-communicable disease control is yet another grey area where the country needs to make considerably more progress, encompassing the prevention and control of diabetes, cancers, cardiovascular disorders, chronic respiratory diseases, and mental health issues which constitute a huge slice of our burden of disease pie. Then although Pakistan is on the verge of Polio eradication, it has yet to touch zero level and sustain it for three consecutive years to contribute significantly to global eradication efforts. The scale of malnutrition in Pakistan warrants radical measures across the country. We have also to come to terms with issues like climate change, and the provision of healthcare as a human right

An emphasis on social health protection has led to an unprecedented and laudable effort of providing health insurance to 140 million persons without any premium or co-payment, however, its sustainability needs to be ensured to reinforce the confidence of the masses. Linking health to poverty reduction appears to be the legitimate pathway to attaining Universal Health Coverage using the PHC philosophy. Efforts to check population growth must also be made part of the priority agenda as it will have implications for reduced poverty, maternal mortality and infant mortality while having a positive impact on economic growth.

Additional efforts will also be required to reverse the health losses suffered due to the ongoing COVID-19 pandemic. As I write, the pandemic is in the remission phase. While Pakistan has acquitted itself quite well in containment measures, there is no predicting when it may re-emerge to disrupt routine health functions as it did previously. Above all, policymakers need to realize the importance of investing in Health in achieving better outcomes. The development partners including WHO, UNICEF, UNFPA, WFP and FAO, in addition to donor agencies need to sync their efforts with Pakistan’s public policy more robustly in a concerted manner, keeping in view their comparative advantages, to bring about a significant improvement in the health, nutrition and population indicators. Meanwhile, as one of its pensioners, I wish a Happy 74th to WHO and wish it continued and accelerated success in all its endeavours.

The writer is a senior public health specialist in Pakistan and Editor in Chief (Public Health Action).