September 7, 2003

‘Any change for the better can only come if the government agrees to re-set its priorities; from making nuclear bombs, beefing up the army, buying submarines and F-16s, to the social sector,’ argues Dr Shershah Syed

IF you look at the statistics given by various international agencies, it makes for very glum reading with Pakistan’s major health indicators clearly demonstrating a large unmet need. Estimated infant mortality is 85 per 1,000 live births, under-five mortality is 103 per 1,000 live births, and maternal mortality is 533 per 100,000. Contraceptive prevalence is only 28 per cent, and the population growth rate is 2.2 per cent per year (compared with India’s 1.7 per cent).

Immunization rates are low with less than 60 per cent of one-year-olds fully immunized. Twenty-six per cent of children under five are moderately to severely underweight; only one per cent of young children receive Vitamin A supplementation; and only 19 per cent of households use iodized salt.

Despite 5,000 graduating doctors every year, and no proper policy of control on medicines, there are some six hundred thousand quacks going about happily with their medical business. The subsequent governments as well as the Pakistan Medical and Dental Council have dismally failed in their endeavour to control the problem.

And despite the National Health Policy’s vision based on the health-for-all approach, the Expanded Programme on Immunization seems to be in doldrums. In fact, the coverage of immunization for six preventable childhood diseases has declined.

We have not been able to protect our people against hazardous diseases or upgrading curative care facilities. Even after 33 sessions of polio campaigns, the Health Ministry has been unable to eradicate it completely. Pakistan is among the 22 countries that carry almost 80 per cent of the global TB burden. In effect, if we look at our health indicators, we are, among the underdeveloped nations, perhaps, just a little better off than Afghanistan and the sub-Sahara region.

According to Improving Women’s Health in Pakistan, a new World Bank report, women’s healthcare does not place enough emphasis on the unique risks associated with childbirth. Every year, some 30,000 young women die for not getting the basic health facilities and 375,000 pregnant women suffer from various pregnancy-related problems.

In a recent interview to Dawn Magazine, Dr Shershah Syed, who is the central head of Pakistan Medical Association, spoke in detail about the various problems plaguing the country’s healthcare system. While he enthusiastically offers practical solutions, his fear is that nothing will happen in his lifetime. The following are the excerpts from the interview:

Q. What ails our healthcare system?

A. It is a lack of good governance and non-implementation of policies. The government without any parliamentary debate formulates policies and the politicians are hardly bothered. The PMA recently sent an open letter to all the members of the national and provincial assemblies citing the problems that beset the healthcare system. Out of 1,500 or so members, we received acknowledgements from only 15. That shows the level of commitment at that level.

Healthcare depends directly on economic growth. Our economic system is completely messed up, with the result that there is rampant poverty. Poverty often breeds corruption and this is true in the health sector, too, where money given by international agencies is smoothly siphoned off from legitimate projects.

The poor have large families as they see children as their insurance. Some will die and others will be undernourished and the mother’s haemoglobin will drop to as low as seven after each pregnancy. Yet, the vicious circle that they are caught up in continues. Give these same people safe, clean water, a working sewerage system, provide them with latrines and you will see half of our problems will go out of the window. Provide them with education as well, and eighty per cent problems will be solved. It’s a very simple formula.

Then again, even our medical colleges have not been free of political unrest. The principals do not enjoy any authority. From admissions to getting a lectureship, all fall under the purview of the provincial government. The latter have made a complete mockery of this, with the result that anyone can open up a medical college in any apartment or a house and run it. Recently, when the King Edward Medical College principal refused admission to a son of a notable, he was forced to resign. These are not isolated incidents; these are links in a chain of events that betray our incapacity to behave like modern nations.

Q. So, if economic conditions improve, then health automatically improves?

A. Not always. There are some poor countries where the healthcare system is impeccable and free of cost. Take the case of Sri Lanka. They have primary and emergency health services available. And their healthcare system is based on the premise that prevention is better than cure, like the immunization of preventable diseases.

Q. Our health delivery system seems to be well designed, then why is it failing?

A. There is nothing wrong with our three-tier system with a Basic Health Unit (BHU), a Rural Health Centre (RHC) at the tehsil level, and then a tertiary-care hospital in the urban area, but the problem is that these units are not equipped. In the BHUs, there are no doctors or even compounders. An RHC should ideally have a physician, a gynaecologist, a blood bank, transportation etc., but none of these basic facilities are there. If you see the 250-bed district hospital in Thatta, you would be horrified.

Q. Is our country not producing enough doctors?

A. We produce more than our share of doctors. Unfortunately, the 70-80 per cent of them go abroad as the nation cannot offer them anything. The bright among the remaining are often without financial aid, and prefer to stay only in the cities.

Q. That is, perhaps, the crux of the problem; the doctors don’t want to serve in remote areas?

A. That’s another distorted truth. Even getting a job in a rural area requires getting through tiresome red tape. There is so much unemployment among doctors that they would readily take up a job anywhere. I challenge anyone who says our doctors are unwilling to rough it out in th villages. Give them respectable pay, comfortable living quarters and a reasonably equipped BHU, and I can line up scores of doctors who are jobless and are willing to go anywhere. After all, these are the same doctors who serve the uncultivated and completely uncouth bedouins in the deserts of the Arab world, because they get proper money.

Forget the remote areas, there are plenty of goths and slums within an hour’s drive time from Karachi alone with populations in the range of two to three lakhs, and there is not a single doctor in sight. Why can’t the government post doctors and staff in such areas?

Q. If there is the need, and there are plenty of doctors available, what is the hitch?

A. The government does not have the resources. Our health and education budget together makes for one per cent of the total. While there is no denying that the government has periodically increased the health budget, has it benefited the poor? Then some 60 per cent goes into the slot of salaries, and the remaining is siphoned off into the slots of pilferage and corruption.

Q. According to a recent report, the private sector accounted for 77.2 per cent of the total amount spent in the health sector in 2000. The government seems to be encouraging private entrepreneurship and shrugging off its responsibility. Comment.

A. The private sector may be providing about 50 per cent of all healthcare services in urban areas, but in rural Pakistan, 70 per cent of health services are still met by the government health provider.

Q. Is there a marked difference in the doctor-patient ratio?

A. Yes. Actually, statistics show that there are 600 students per 520 beds per year when ideally there should be 15 beds per doctor per year. The obvious result is that there is absenteeism and people work in a disorganized manner.

And while we have so many doctors, in direct proportion, we have an acute scarcity of nurses with one nurse for eight doctors as opposed to the ideal 15 nurses for one doctor. Our paramedics and technicians are also in short supply.

Q. What is your opinion of the National Health Policy and how far has the vision regarding health-for-all materialized?

A. Our health policy is in a mess and is not addressing the real issues. I don’t think that with the present health policy we will be able to have healthcare for all even in the next fifty years. We need revolutionary changes. Working at the grassroots, I feel this now, more than ever, that the policy-makers are working in a world of their own, away from the ground realities.

Q. What can be done to straighten things out?

A. There have to be a stringent measure for checks and balances in place, and the government, if it aims at health for all, has to increase the health budget. We must also attach the hospitals in the periphery as well as those at the taluka level to the tertiary-care hospitals so that the excess of doctors serving in the latter hospitals can be sent to the former. We also need to invest in the nursing profession and give it the status it duly deserves. We need to have more quality training institutions for paramedics and technicians. And, lastly, the unpleasant elements need to be weeded out from the medical colleges.

Q. Can it be done?

A. Only if the government’s priority shifts from making atomic bombs, beefing up the army, buying submarines and F-16s. But in my lifetime, I don’t see this happening. In England, the budget for health and education form 22 and 26 per cent respectively, and 18 per cent on defence. It is easy to see what we are doing with whatever money we have.

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