IT may sound premature to talk about ‘thereafter’ when the third wave of Covid-19 is raging. But it isn’t really too early. How countries respond to health emergencies is a direct function of how prepared they were at the time the emergency struck. Indeed, ‘health emergency’ can be a pure health issue, like the pandemic, or it can be corollary to any other local or national catastrophe such as earthquakes, floods and famine.
As the Covid-19 experience has shown, we were least prepared to face a health emergency. Despite Pakistan being prone to disasters, we have not systematically invested in health-related emergency preparations and hence our haphazard responses. The range of our lack of preparation for health emergencies extends across policies and operations. In 2016, WHO sponsored an independent evaluation of our “core capacities” to prevent, detect and respond to health threats in Pakistan. A big team of international experts spent weeks across the country to assess in detail 19 technical areas in the context of the International Health Regulations (2005) including the state of pandemic preparation. The evaluation team produced an elaborate report with detailed recommendations to improve the national health emergency infrastructure and operation but there has been hardly any implementation.
Currently, Pakistan lacks even the legal basis for declaring a national health emergency. Ministries of health are least prepared to generate health emergency responses on their own. The 18th Amendment has further weakened and complicated national coordination during emergencies on a national scale. Even the National Disaster Management Authority lacks close operational coordination with its provincial counterparts. If there was a coherent national disaster management institutional network there would be no need to establish the National Command Operation Centre. Likewise, the Central Health Establishment, a weak, ill-mandated organisation under the Federal Ministry of National Health Service, Regulation and Coordination, is responsible for screening and quarantining at 19 points of entry (airports etc.) in the country which is a vital function during a pandemic like Covid-19. This organisation needs a complete overhaul.
We also lack a robust and reliable national disease surveillance system and a resourceful rapid response team in each district led by a field epidemiologist. There is also an acute shortage of ICU beds and critical care specialists in Pakistan. As the number of critical patients goes up, our system starts shuddering. A robust ramp-up planning in this regard is needed.
Currently, Pakistan lacks even the legal basis for declaring a national health emergency.
Experts had been predicting a global pandemic for some time. It does not seem that Covid-19 will end anytime soon, nor is it the last pandemic. Who knows when and from where the next pandemic, or for that matter any other kind of health emergency, will hit us, and how lethal it will be. What we have learnt from the Covid-19 experience is to prepare ourselves better for the future. Lessons need to be learnt in the global arena as well as in national settings.
The world is rife with all kinds of inequities including in healthcare. As Covid-19 has shown, highly resourced health systems of high-income countries are also not shielded from the pervasive effects of the pandemic. The current scramble for vaccines has also exposed the inequities between rich and poor countries. Low-risk adult populations are being vaccinated in high-income countries whereas high-risk front-line-health workers and old people with co-morbidities are waiting for their vaccines to arrive. A similar situation exists between the haves and have-nots in poor countries where children of the rich are getting vaccines from the private sector whereas the old and frail and poor are waiting for their turn in the public sector.
Covid-19 has exposed health systems around the world. Just as after World War II, the international community learnt its lessons and said ‘never again’, a similar level of response is needed now to fix healthcare in the world as part of the Covid-19 recovery plan.
Countries need to reset the vision of their healthcare systems to primary healthcare-oriented universal health coverage. The case for investing in healthcare is strong and its positive externalities impact not just health but also national productivity, human development and economic growth. The health workforce needs to be trained in accordance with national health needs and priorities. Essential medicines and technology should be accessible to all and supply chains should be fixed and made transparent and efficient. Health services must go beyond treating patients and include preventive, promotive, rehabilitative and palliative services.
Essential public health functions like disease surveillance, disease control and regulation of the health sector need to be strengthened. Emergency preparedness and response must be considered as an integral component of healthcare. Health is a cross-cutting phenomenon and needs a whole-of-government and whole-of-society approach. It is not just health ministries’ responsibility. Many important determinants of health are out of the realm of health ministries, eg water, poverty, education, risky behaviours. A major priority should be to strengthen primary healthcare. This is where the majority of cost-effective healthcare services can and should be provided.
Pakistan has abysmal health indicators. Mother and child health is in a shambles. Communicable diseases are rampant and the incidence of non-communicable diseases is dangerously high. Our health system is urban and hospital-oriented, private-sector dominated and least regulated. Public health functions were never strong but are now hugely fragmented after the 18th Amendment. Pakistan is a low spender on health even in comparison to low-income countries and the fiscal space has shrunk further after Covid-19’s impact on the economy. Yet, more than ever before, we need to pay serious and sustained attention to our healthcare system.
Covid-19 has shaken us. As the pandemic recedes, we need to fix our healthcare on a war footing before we are hit by another calamity. We should set up a national commission on health which should undertake a quick review and make bold and far-reaching recommendations to enable us to provide decent essential healthcare to all and prepare us to deal with major health challenges including future health emergencies. Expenditure on healthcare should be seen as an investment rather than a social overhead.
The writer is a former SAPM Health.
Published in Dawn, April 9th, 2021