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Healthcare in new growth strategy

March 25, 2012

THE World Health Organisation warned last week that Pakistan could face travel and visa restrictions if it failed to contain the spread of polio virus.

That was perhaps the first expression of anxiety over widespread reporting of polio cases by the international community that has invested billions of dollars in Pakistan over the last few decades. Before this, the outbreak of dengue virus claimed over 200 precious lives last summer.

On top of that, the recent deaths caused by spurious medicines in public sector hospitals brought to the limelight that there is something seriously wrong with the affairs in the public health sector.

As if that was not enough, the repeated strikes by young doctors in Punjab and the federal capital for improvement in their working conditions including remuneration packages suggest that the public health lacks the policy focus it deserves.

In the larger context, it is far more important for a nation not only to invest in human capital through health and education but also to focus on result-oriented policies for raising national productivity and economic growth.

It is universally recognised that better life expectancy reduces mortality, particularly in below 40-year age group, makes much larger contribution to productivity and growth.

Malnutrition severely impacts health, education and productivity, results in increasing poverty and retards economic growth, according to Dr Talib Lashari, advisor on health to the Planning Commission.

In his view, the broader goals of development like poverty reduction could partly be achieved through enhanced investment in provision of cost-effective health services to the poor.

Similarly, investing directly in poverty reduction and education especially, of girls, results in improved health. If nexus of poverty-health-education is addressed appropriately, it will transform into economically active and healthy human resource — one of the prerequisites for sustained growth.

It is in this background that the Planning Commission has included health in its new growth strategy. As a follow up, an health insurance scheme has been made part of the Benazir Income Support Programme (BISP) under which the government plans to launch a pilot project in Faisalabad that would provide up to Rs25,000 per year of insurance per family for health related expenditure. The project would be extended to 16 other districts to cover about 60,000 families out of about five million registered BISP beneficiaries.

Dr Lashari argues that one of the challenges is to build ‘human health capital.’ While many previous policies and plans have contributed towards this end, when seen against national and international parameters, national policy goals, millennium development goals and health status of countries with same level – the policy planning conduits could not meet expectations of the people and the policy makers, he said.

One can witness lack of proper implementation on policies, monitoring and evaluation, result-based management and governance. Socio-economic disparities impact on the health status of the populations.

According to Pakistan’s MDGs report 2010, health-related targets would not be achieved by the year 2015 unless some extraordinary measures are taken. The under-5 mortality rate and infant mortality rate may not be reduced to 42 per cent target. Likewise, the immunisation coverage of children between 12-23 months has been increasing at a very slow pace.

The maternal mortality ratio is unlikely to be achieved since proxy indicators regarding maternal health i.e skilled birth attendants’ coverage and contraceptive prevalence rate do not show the required progress.

Furthermore, increasing burden of non-communicable diseases has over-stretched health system. As non-communicable diseases rank amongst top ten diseases causing morbidity and mortality, alarmingly, such diseases cause 67 per cent of total deaths in the country.

Pakistan is among the top ten countries as per the ranking of diabetes with 5.2 million people affected while 27 per cent of the population over the age of 40 suffers from cardiovascular diseases attributed to risk factors like smoking, high blood pressure, raised cholesterol and overweight.

And the root cause of these diseases could be found in unplanned urbanisation, globalisation of trade/marketing, and unhealthy lifestyles, thus emerging as a serious macroeconomic and developmental challenge, according to Dr Lashari.

On top of that, the maternal malnutrition is estimated at 26 per cent and is resulting in low birth weight babies. The nutritional status has not changed for over a decade. Moreover, the macronutrient deficiency of iron, vitamin-A, iodine and zinc, singly or together, leads to growth retardation, decreased learning ability – lower IQ disability, mental and physical retardation, night blindness, goiter and pregnancy complications. The results could be anybody’s guess.

At the same time, while the per capita availability of cereals, meat and milk has increased, the availability of pulses, sugar and fruits and vegetables has shown a declining trend. The per capita caloric and protein availability during 2005-10 has also increased from 2370 to 2420 calories and protein 70 to 72 per cent.

However, there is a huge gap between availability and affordability. The food consumption according to Household Income and Expenditure Survey of 2010 has shown declining trend from 1700 to 1650 calories due to increasing food prices and eroding purchasing power of common citizen.

Despite impressive health infrastructure across the country, there is under-utilistion of first care level facilities and over-utilisation of tertiary facilities while secondary tier facilities have been working in isolation. As a result, private health facilities have mushroomed over the years, resulting in two-third of health expenses met through private means.

Private expenditures reportedly contribute 64.5 per cent of total health expenditure out of which overwhelmingly 99.6 per cent are out of pocket expenditures and only 0.23 per cent spent through private insurance.

While Pakistan has one of the best available health infrastructures and human resource specifically trained doctors, these are not fully utilised and translated into acceptable level of health status. That mirrors poorly on policies and their implementation.

The fundamental issues regarding poor health indicators and programmes’s performance suggest weak health system, weak linkages between policies and plans. In addition, socio-economic disparities, weak oversight mechanisms of programmes and centralised institutionalised mechanisms were some of the major factors responsible for poor outcomes, says Dr Lashari.

He argues that while there is a need to expand pre-hospital care facilities like 1122 in Punjab and other provinces, there is an urgent need to synchronise federal and provincial health policies through coordination on licensing, registration and pricing of drugs, perhaps through Council of Common of Interests.

In order to harness the benefits of economic growth framework, two strategies in health sector should be followed. First, health reforms outside health sector and second, partnerships in health sector to make it more efficient and responsive to the public needs.

There is also a need to integrate preventive, maternal, child health and nutrition programmes and making district headquarter hospitals (DHQs) into independent functioning modern facility through public-private partnership, besides pursuing introduction of health insurance.