A flawed scheme

22 Jan 2017

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“PEOPLE do not have enough money to buy medicine. They don’t even have enough money to travel to the hospital. I would wonder how they are managing,” said the prime minister recently at the launch of a new health card scheme in Narowal.

One wishes someone would tell him even if people manage to get to the hospital they do not have enough to pay the doctors — that is if they are lucky enough to see one, and who knows what quality of service they receive. Most do not even have enough money to buy adequate food. Managing? People are actually dying.

Pakistan ranks low on the social development index of child and maternal health, which reflects the level of nutrition, education and access to health services. Pakistan’s Maternal Mortality Ratio Index has slipped from 147 in 2014 to 149 in 2015. The overall maternal mortality rate is 276 per 100,000 live births, but in Balochistan the rate is as high as 785, with less than 10pc of pregnant women receiving vaccines and immunisations.


Health cards are not the solution.


Pakistan has the third highest child (under five) mortality figures in the world, and 40pc of these deaths occur in the neonatal period. According to the Pakistan Demographic and Health Survey 2012-13, 45pc of children show evidence of chronic malnutrition or stunting and 11pc are acutely malnourished, requiring urgent treatment.

In 2014 and 2016, there were excessive deaths in children in Thar, due to endemic malnutrition and water-borne diseases. In 2014, pneumonia and diarrhoea had claimed the lives of 144,000 children nationally. These deaths from ‘ordinary diseases’ are more than terrorism-related deaths.

The government of Pakistan is signatory to the Sustainable Development Goals, which call for universal health coverage by 2030. The government also makes this commitment in its health policy.

In 2017, 80pc of Pakistan’s population is without access to primary care. Families are forced into poverty as a result of crises related to private healthcare expenditures. In addition to access, quality of care is uneven.

Understandably, something needs to be done. But that something should not be the likes of a one-off health card scheme that will die when it’s funding (from the World Bank) runs out. Or grand delusional plans that do not even materialise, as those put forward by the Sindh government. It offered to form the Thar Development Authority, which was to “develop proper infrastructure and civic facilities in the district and improve living standards of residents”. The Sindh government made a similar offer in 2014 during the Thar crisis.

Similarly, distributing health cards will not work. One, it only covers hospitalisation, and these people have nowhere to get healthcare other than from the existing health facilities — 965 tertiary and secondary hospitals, 13,051 first-level care facilities in the public sector, and 73,000 in the private sector.

Most private facilities are unregulated with dubious quality of service, and public facilities have consistently shown to be unusable due to systemic issues. There are long distances to facilities, restricted hours of operations, poor facility infrastructure, lack of staff (especially doctors), equipment and supplies. Since there is no service available, what use is the health card?

Given the magnitude of healthcare needs and finite resources, neither the government nor private organisations can address this challenge alone. However, the responsibility for addressing it rests with the provincial government. It needs to be thoughtful and build viable models of services, in partnerships that ensure access to and quality of services. These models should include universal health coverage systems that are well aligned and synergistic, financially sustainable, and that match government needs with private-sector offerings.

The first step towards that end could be to make public-sector facilities usable — so there is service available. The provincial government should fix the infrastructure (that includes livable living quarters for staff), make sure staff is available (pay them well and on time) and provide the equipment, supplies and drugs needed to serve the citizens. All these items are included in the Planning Commission documents, which means the finance department has sanctioned the funds for these items.

In taking suo motu notice (November 2015) the then chief justice Anwar Jamali ordered federal and provincial health Secretaries to explain why the governments had turned a ‘blind eye’ to the disturbing health situation in the country. In August 2016, the Supreme Court described the situation in government hospitals in Islamabad as “pathetic and shambolic”.

These are serious allegations. Provincial governments must act responsibly and understand that empty words or other short-lived, donor-funded gimmicks do not solve life-threatening problems.

The writer is a public health specialist and author of So Much Aid, So little Development: Stories From Pakistan.

Published in Dawn, January 22nd, 2017