IN the face of stark adversity, a drop of ‘re-imagination’ has fallen in the stagnant, stinky waters; stirring them, and creating the first small ripples. I hope the ripples grow into waves. Things have to bounce back after hitting rock bottom. It is the physics of societies.
My last column in this space had simply listed some of our dubious distinctions in health. I ran the risk of being dubbed a ‘naysayer’ or ‘pessimist’ but I went ahead. It was widely noted. Miftah Ismail used the data in the first Reimagining Pakistan seminar in Quetta and tweeted his acknowledgment — thank you.
Seldom have I received so much feedback for an op-ed article. The gist of almost all the responses was this: very sad but very important to talk about it. Some of the responses reminded me of what I have missed out in this list of tragedies. These are good signs.
What is the way out of this quagmire? Let me speak first in broad strokes before approaching the minutiae.
First and foremost, we can rest assured that our tragic health indicators are reversible. Most of these conditions are preventable. For those always moaning about the lack of fiscal space for health, the return on investment on preventive public health interventions is extremely high. So, it is good value for money and a profitable business transaction.
Just one example: according to an estimate by So Yoon Sim, et al in 2020, the return on investment on one US dollar spent on immunisation against 10 pathogens in 94 low- and middle-income countries, using a value-of-statistical-life approach, would be $52.2 from 2021 to 2030. Can you beat this return on investment? Cost-effective interventions are available for almost all our health problems.
Elitism has permeated healthcare, as it has every other sphere of life in Pakistan.
But let us start with a more basic issue. As we all know, human health and healthcare are existential human needs. Suffice it would be to remember our last sickness. Remember Covid-19? ‘Jaan hai to jahaan hai’ — life is the most precious thing — was the mantra echoing in the long silences of our isolation.
Instinctively, we would not barter our own health for anything (damaging others’ is another story). This was the basis on which the constitution of the WHO was founded in 1948, defining health in physical, mental and social well-being terms and also establishing it as a fundamental human right without any discrimination with regard to race, religion, political belief, economic or social condition.
It was also considered fundamental to peace and security. Unequal development in different countries in the promotion of health and the control of disease, especially communicable disease, was considered a common danger, as it became greatly evident during the global pandemic. And governments were considered responsible for the health of their peoples. Signing this syntax of health as members of the WHO, one after another, states started sanctifying the right to health in their constitutions. One analysis shows that until January 2020, 74 per cent of national constitutions were explicitly protecting some aspect of the right to health for all citizens. Pakistan’s Constitution sadly doesn’t provide an explicit right to health. The related provisions are weak and vague.
A good starting point to reimagine healthcare is by making a constitutional amendment for right to health, as was done through the insertion of Article 25-A for right to education as part of the 18th Constitutional Amendment. All political parties should come together to agree on this and table a bill to this effect after the next election.
Secondly, once the right to health is established, then the policy of universal health coverage should be implemented with full force. Our national health vision and current five-year development plan are already oriented towards UHC. Pakistan has developed, at the federal as well as provincial level, cost-effective essential health services packages.
It is a significant development over the last three to four years. Ensured sustainable provision of 88 priority health services at the district level can take care of the majority of healthcare needs of the population.
Despite having only 88 services, the comprehensiveness of the package is testified by the fact that even mental health services are included for the first time to be delivered at the primary health care (PHC) level.
The solution to our healthcare problem lies in strengthening PHC, which we have ignored. Elitism has permeated our healthcare system, as it has every other sphere of life in Pakistan. We perceive PHC through BHUs and RHCs as poor healthcare for the poor. In our minds, big hospitals in big cities with specialists constitute good healthcare.
This has inevitably resulted in higher allocations for tertiary care at the cost of PHC. Serious and sustained implementation of these packages at PHC level can transform healthcare and improve our shameful health indicators in the next few years. This requires a new financing strategy and a trained health workforce.
The other critical part is ensuring that the provision of these services covers everybody, including those who cannot pay. Financial protection schemes for the poor and other vulnerable groups is an integral part of UHC. The Sehat Sahulat Programme in Pakistan is a great response to this aspect of UHC.
Since around 60pc out-of-pocket expenditures for health are made in the private sector, keeping in view the inelasticity of demand in health, people, especially the poor, incur huge costs in buying healthcare in the private health market.
The SSP was envisaged and publicly financed to provide financial protection only to the poor and vulnerable for hospitalisation. But, alas, for entirely political reasons, the programme has been universalised for rich and poor alike. Keeping in view society’s power dynamics, the poor and vulnerable are going to be pushed to the margins.
Nor is it financially sustainable in the long run. The programme is also limited to hospital admissions and does not cater to ambulatory primary healthcare. All these issues demand serious and appropriate reforms. We will continue this discussion.
The writer is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University and WHO adviser on UHC.
Published in Dawn, January 27th, 2023
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