Expecting Pakistan’s chronically underfunded health system to provide first-rate response to a pandemic of the magnitude of Covid-19 is like expecting a severely malnourished child to perform well at school and grow up to be globally competitive. No one will disagree that combating Covid-19 is no less than fighting a sophisticated non-traditional war against an invisible enemy. Any military strategist, or in this case an insightful epidemiologist will tell you that fighting such a 'viral war' requires years of preparation and the ability to mount an effective response if disease, disability and deaths are to be averted.
The federal and provincial governments, led by no less than Prime Minister Imran Khan and the respective Chief Ministers, the federal Ministry of Health Services Regulation and Coordination, the Provincial Health Departments, the Armed Forces, National Disaster Management Authority, other governmental and non-governmental organisations, and academic institutions in the country have made great efforts to blunt the Covid-19 epidemic in Pakistan. The presence of qualified health ministers at the federal and provincial levels in such troubled times has also been be a plus point. These efforts, as important as they be, are being made ex-post. Will these be able to flatten the epidemic's curve in the country, only time will tell. There is no ambiguity that based on current trends the peak is yet to come.
Let there be no doubt that Covid-19, which has stretched to the limits some of the most robust health systems in Western Europe and North America, will relentlessly test the more fragile health systems of many low and middle income countries such as Pakistan. While this is not the point in time to be unduly critical of Pakistan’s health system, it is nevertheless important to know why our national health system is so weak to respond to such an overwhelming challenge.
First, Pakistan is among the lowest spenders on health among low and middle-income countries. The government spends just about 0.7% of its GDP on health and it turns out to be no more than 12 USD per capita.
Second, there is a huge shortage of health workforce in terms of numbers, cadres, distribution and quality of training. This is especially the case for nurses, pharmacists, dentists and other allied health professionals. Pakistan’s workforce density of 1.75 per 1,000 population falls far short of the minimum level of 3.45 per 1,000 population as recommended by the World Health Organisation.
Third, the shortage of health infrastructure such as hospital beds, diagnostic laboratories, radiology and imaging, blood transfusion centres, and other facilities specially in the districts obliges the population to seek care from urban-based tertiary hospitals, stretching these well beyond their capacity.
Fourth, the capacity in terms of essential public health functions such as disease surveillance, emergency preparedness, prevention, protection and promotion are at best weak and unfortunately rely on external financing by different donor and development agencies.
Fifth, Pakistan missed the opportunity to eradicate polio in the early 2000s. Its current effort to meet the global target comes at the cost of ignoring several other priority health programmes as polio eradication takes at least half the time of the district health workforce.
Finally, poor governance and management of the health system in terms of weak oversight, regulation, partnership, monitoring, accountability and the like along with inherent corruption and system leakages underpin its poor performance in health.
This has been further exacerbated by devolution in the health sector that falls short of empowering the districts where essential health services need to be delivered. Weak governance in health is the consequence of poor overall governance in the country, which relies heavily on an archaic structure of civil service that has yet to inculcate a mindset to serve its people.
What does this mean for managing Covid-19 in Pakistan? Despite the many shortcomings in the health system, it is doing its best and like many other crises the nation will overcome this one as well.
Hopefully, this will happen with as little damage as possible to the lives and livelihoods of Pakistanis. Based on the foregoing, there are lessons to be learnt to strengthen the health system as the country may not be able to face another challenge of such proportions in the future. The most reassuring feature of the Covid-19 epidemic is that its prevention relies as much, if not more, on community participation and population level interventions such as social distancing, hand hygiene and self-isolation as it does on a mature health system. This is how China controlled the epidemic and other countries are following suit. Pakistanis should rise to the challenge, practice these preventive measures and use this as an opportunity to demonstrate the nationhood that seems to have dimmed in recent decades.
Finally, the Prime Minister of Pakistan in his recent speech to the nation highlighted the importance of 'Iman' or faith as a strategy to tackle this pandemic. Indeed unflinching faith in God Almighty is something that we all have, yet faith will only work unless there is a desire to change as stated in the Surah Ar Ra’ad: Indeed, Allah will not change the condition of a people until they change what is in themselves [13:11].
Dr Sameen Siddiqi is the Professor and Chair, Department of Community Health Sciences, Aga Khan University, Karachi. Earlier, he served in the World Health Organisation as Director, Health System Development, in its Regional Office in Cairo, as well as its Representative in Lebanon and Iran.