March 08, 2008	Saturday	Safar 29, 1429

BAHAWALPUR, March 7: Delivering healthcare in rural areas has long been problematic in Pakistan, where factors such as a lack of trained health workers, poor access to remote areas, and the locals’ preference for quack medicine over modern science, not to mention a lack of political will, have conspired to keep rural dwellers in much the same state as they have been a good 60 years ago.

The first signs of a concerted effort for change are now showing, however. As part of its effort to meet the eight UN Millennium Development Goals (MDGs) by 2015, the government is stepping up its healthcare outreach in rural areas, with new schemes to combat disease and raise awareness of basic hygiene.

The NCHD was set up in 2002 for facilitating existing government programmes by bringing in new funding and expertise. But it has been facing problems in achieving the targets. Amir Bilal, a spokesman, explained: “Our foreign donors and international agencies such as the World Health Organisation are becoming increasingly frustrated that despite all the aid pouring into this country, little or no difference is being detected on the ground, and they suspect their money is not going to where it should have been.”

In terms of healthcare, these days it is concentrating on streamlining delivery of healthcare by recruiting more workers and setting up a comprehensive database (called a “baseline survey”) of the health of hundreds of thousands of citizens who make up every district.

Dawn travelled to the NCHD field office in Bahawalpur to see just what exactly it was doing to meet its goals. Among its objectives are reducing infant mortality rate and under-five mortality rate by 35 per cent, reducing maternal mortality rate by 30 per cent and reducing population growth rate to less than 1.5pc per annum. There is another side to the picture. The government agencies are often accused of lavishly spending on office equipment and perks. Yasir Ali, the general manager of the Bahawalpur field office, was at pains to dispel any such notions. He told Dawn that despite being given Rs35,000 to outfit his office, he managed to spend only Rs16,000. And the row of four-wheel drive vehicles parked outside the office was used for official work only and none of his staff used them to travel to and from work, he said.

In order to meet the needs of Bahawalpur’s 3,194,099 residents, the NCHD plans to set up a total of 107 Basic Health Units which act as the first line of defence in terms of disease prevention and cure. In the three months it has been operational in the district, the NCHD claims that it has now brought 21 BHUs to the required standards – with adequate facilities, computers and staff. Previously, some BHUs existed only on paper and lacked basic facilities.

More serious illnesses are referred, pyramid-style, to district hospitals, and finally the most serious to the Bahawal Victoria Hospital.

The project includes training of all important Lady Health Workers whose task is to arm villagers with basic hygiene knowledge and conduct health screening, as well as imparting skills such as how to make home-made Oral Rehydration Salt (ORS) in case of diarrhoea.

Amna Farid, a health worker in Yazman tehsil, explained: “We workers are all local, and because of that we’re able to penetrate more readily into society. Outsiders don’t get the same access.”

These workers, who usually have some basic education to around 8th grade, are also expected to deliver contraceptives to residents’ doors, in keeping with cultural sensitivities, and carry out basic health checks on children. To supplement their work, male “social mobilisers” hold community meetings of up to 200 people, and communicate the same ideas to the men of the village. One problem with the system is that at times, the work of the lady health workers is not accepted by the males of the village. Then the work must fall to the male social mobilisers – who haven’t been given any medical training. A structural rethink may be required in this regard.

Further essential programmes include eye-camps conducted for school children. “Poor eye-sight, and, as a consequence, poor class attention, is one of the leading causes of dropout,” said Amir Bilal.

Finally, there is the Baseline Survey programme, whereby a comprehensive health survey is made of the entire population of the district, and fed into a computer database.

Dr Shamna Syed, a recent graduate who returned to her hometown of Bahawalpur and commutes 45km to the village of Yazman, said: “Now, whenever we want to see which areas haven’t been vaccinated, we’ll just get the info at the click of the button. It’s going to make a hell of a difference.”

She admitted, however, that difficulties remain in overturning long-held attitudes towards conventional medicine. “When a quack lives two houses away from you, why would an uneducated villager come here?” she asks.

While it may be tempting to describe this overhaul as revolutionary, shortcomings do remain. Though the survey is described as “comprehensive”, no provision is made for HIV/AIDS or other sexually- transmitted diseases listed as a key part of the UN MDGs.

When administrators were questioned regarding their overall budgetary figures, they usually did not have the information to hand, despite being a publicly-funded organisation. The district’s chief medical officer could not answer how many doctors work in the entire Bahawalpur district, nor could he offer a rough guess, throwing into doubt how well tuned to ground-realities some administrators are.

Furthermore, critics question the wisdom of hiring a third-party agency such as the NCHD to run programmes that existing government departments, such as the department of health, are supposed to be doing themselves.

Yasir Ali insists that when the NCHD completes its mission, it will withdraw from the area and allow the local authorities to continue their work, though there is no guarantee that they won’t revert to old habits. That will depend entirely on continued funding to the local health department. And withdrawing the NCHD field office in a year’s time would also translate to a loss of dozens of jobs.

Finally, a pre-planned visit to one field office by journalists can hardly be termed an adequate check on the entire system, and perhaps the future lies in the creation of an independent body dedicated to ensuring standards are maintained.

Nevertheless, in the sites visited by Dawn, a sense of optimism has begun to take hold. Though the road to good rural healthcare may be long and arduous, the journey has now begun.