ALTHOUGH Pakistan faced a long-standing healthcare crisis even before Covid-19 reached the country and began its spread, the potential scale of the pandemic’s devastation has brought the weaknesses of its health system to the fore.
Successive governments in Pakistan have not made serious efforts to develop a healthcare system that delivers quality and affordable services to a majority of the country’s population. While some specific health-related issues receive heightened short-term attention from the government and media — for example, the rise in polio cases, spread of HIV and now, of course, Covid-19 — the systemic faults in our healthcare system remain largely unaddressed. The result is appalling health indicators, high rates of mortality and morbidity from preventable causes, and severe financial hardships for low-income households seeking access to health services.
While many countries in the world, including developing countries, are taking steps towards universal health coverage, Pakistan is lagging far behind in this goal. According to the World Health Organisation, ‘universal health coverage’ means that “all people have access to needed health services of sufficient quality to be effective while also ensuring that the use of these services does not expose the user to financial hardship”.
Pakistan’s current health policy framework and the nature of its implementation is a far cry from the goal of universal health coverage. Pakistan has a network of public-sector hospitals established to provide health services free of cost. Primary health services are offered at Basic Health Units (BHUs) and Rural Health Centres (RHCs) are spread across districts. District headquarter hospitals are designed to provide a range of comprehensive healthcare services. At the top of the tier are tertiary-level hospitals located in some of the larger cities that are meant to provide a range of sophisticated medical services. The government employs a large cadre of doctors and healthcare professions to staff these facilities.
An injury or disease can be all it takes to plunge a household into deep poverty.
On paper, this is an elaborate government-administered system designed to serve people free of cost through a multi-tiered and inter-linked network. The reality, however, is that this system of government-provided healthcare does not work. At the lower levels, BHUs and RHCs are barely functional. They are poorly equipped and understaffed, and many of these health centres are in fact ‘ghost facilities’.
In the absence of functioning primary and secondary healthcare facilities, our tertiary hospitals are overloaded with patients. A common sight at Civil Hospital Karachi, for example, is patients from all over Sindh and Balochistan, who have travelled to the hospital for treatment, having encountered many disappointments along the way. Doctors at tertiary hospitals will tell you that by the time patients with life-threatening illnesses come to them, it is often already too late.
The consequence of the sparse and low-quality services provided by the public sector means that most people in Pakistan rely on private healthcare. In the absence of a state-supported health financing system, payments for private services are inevitably out-of-pocket.
Effectively, this means that affordable quality healthcare is beyond the reach of large swathes of the population. An injury or disease can be all it takes to plunge a middle or low-income household into debt and deep poverty. For those already below the poverty line, sickness can deplete resources entirely. As a result, poor people often live with chronic morbidities and face higher rates of mortality. WHO estimates that about 100 million people are pushed into extreme poverty every year because of out-of-pocket spending on healthcare. Many of them are likely to be from Pakistan.
Beyond piecemeal and ad hoc measures, governments in Pakistan have made no systematic efforts to overhaul a failed system. Public-private partnerships have been initiated in some districts to fix dilapidated public hospitals. Attempts to introduce government-supported health insurance through the Prime Minister’s National Health Programme in 2016 and the Sehat Sahulat programme of the PTI government have not been consistently implemented.
It is against this background that we are now confronted with a pandemic that has affected hundreds in Pakistan and claimed thousands of lives across the globe. Around the world, the virus has revealed the fragility of healthcare systems that have been depleted by ‘austerity’ economics. In Pakistan, we know all too well that our existing healthcare system is entirely incapable of managing the number of cases projected to arise.
The federal government’s response to the pandemic reflects the abysmal condition of our health system. It was far too slow to grasp the gravity of the problem and enforce necessary precautions. Its confusion regarding key measures such as imposition of a lockdown and suspension of congregational prayers displayed a frustrating absence of leadership.
A silver lining through this has been the proactive response of the Sindh government. Although the public health sector in Sindh is historically neglected, the Sindh government’s approach to the current crisis has been decisive, systematic and evidence-based. In addition to the enforcement of precautionary measures, provisions were made in Sindh to address the shortage of hospital beds, facilities and equipment. This has shown that if the Sindh government chooses to address a problem decisively, it possesses the capability to do so —and to some extent, can even muster the resources to do so.
After we and the rest of the world get to the other side of this pandemic, the Sindh government should extend its leadership role by bringing the same dynamism and thoughtfulness to the implementation of policies that would lead to universal health coverage. Our experience with Covid-19 will hopefully teach us many lessons: one of these should be that it is the lack of political will — not a shortage of financial or human resources — that stands in the way of policies that promote health and welfare for all.
The writer is a lawyer.
Published in Dawn, March 30th, 2020