ALL governments want to spend public funds on schemes visible to the electorate. But the silent advance of chronic non-communicable diseases (NCDs) demanding swift control has slipped through the policy cracks.

Hypertension, cardiovascular diseases, diabetes, lung diseases and cancers together are the leading cause of deaths and disability in Pakistan, striking silently, causing premature death, or lifelong complications.

Experts say Pakistan has the seventh highest number of diabetics, 40pc of people over 40 years are hypertensive, one to two persons out of 10 suffer from depression and, annually, there are over 40,000 breast cancer deaths. Let us not dismiss these as diseases of the wealthy or elderly. In fact, they strike the adult productive population, especially the poor, in Pakistan. Economic losses from lost days of work are huge and medical costs staggering.

The country is already behind the MDGs in several areas. Simple targets such as vaccination coverage for children and skilled providers for delivering babies have not been met. Policy solutions for both uncontrolled chronic diseases and unfinished MDGs lie at the primary healthcare level.

Boosting primary healthcare is key to fighting NCDs.

How prepared are we to control chronic diseases? Pakistan signed the global action plan for NCDs in 2011 aiming for a 25pc reduction in NCD deaths, but did not implement it, while other regional countries made rapid strides.

Perversely, the emphasis in Pakistan has been on specialist hospitals, for example, putting in stents for blocked arteries but overlooking in frontline clinics uncontrolled blood pressure that cause failing hearts. Such strategies are listed as of lowest priority by WHO, and involve up to 10 times the cost and lost opportunities of continuing care at the frontline level. Even the well-endowed Gulf countries put their monies into primary care interventions.

To give due credit, the political parties’ manifestos mention primary care: PML-N and MQM twice, PTI and PPP thrice and ANP four times. But the budgetary allocations underscore the ‘real’ policies of the health sector.

Health is a lucrative sector as seen in the rapid increase in health budgets post devolution, but primary care remains underfunded. The only hallmark effort was the Lady Health Workers Programme in the 1990s by the Benazir Bhutto government.

The health sector’s annual development plans for 2014-15 are typically tilted towards capital schemes for specialist services — across the provinces 56pc to 79pc of allocations are on hospitals, 17pc to 36pc on primary healthcare and 2pc to 5pc on governance.

High-end schemes such as cardiac centres and interferon therapy, are visible and offer opportunity for grafts taking priority away from ‘ordinary’ issues such as the Hepatitis B vaccination to prevent liver cancer or the provision of fasting blood sugar tests at Basic Health Units.

The purchase of a month’s supply of medicine for either hypertension, depression or high blood lipids, even cheap, generic drugs, is beyond the reach of many government workers. And skills for the early management of simple chronic diseases are weak even amongst medics with studies showing that 41pc of diabetes, 35pc of hypertensive and 31pc of depression patients are given faulty prescriptions.

How can we contribute to dealing with NCDs at the primary healthcare level? The best buys from other countries are simple and cost-effective. First, Pakistan needs a core package of health interventions whose per capita cost has been worked out. These would include screening adults when they visit health facilities as in Oman; expanding urban and rural health units to polyclinics as in Jordan, M-Health messaging for patient follow-up as in India, referring risky cases to community health workers as in Sri Lanka.

Second, health interventions must be shifted from specialists to certified family physicians, GPs and other frontline providers, backed with training and treatment protocols.

Third, dedicated governance structures, NCD units, at federal and provincial levels must be established. Only Punjab has made a beginning so far.

Fourth, the private sector needs to be co-opted through either training and accreditation or more aggressive strategies such as regulation and contracting arrangements.

But given the complex lifestyle linked with chronic diseases, action is also needed outside the health sector, at the larger public policy level. Governments should establish cross-sectoral forums at the planning and development level involving the food, excise, road safety sectors etc. Simple policing has worked in other countries — regulations for reducing salt content of processed foods; price increase of saturated oils and carbonated drinks; safe footpaths, etc.

Yes, we have raised the tax on cigarettes this budgetary year, but the test of political will lies in the flow-back of some percentage of tax revenues to the health sector for NCD control.

The author is a policy researcher and faculty member at a private medical university.

Published in Dawn, October 14th, 2014