Poor Health Facilities
 

Pakistan was not a healthy state to begin with. Its sickness began even before its birth. It inherited a legacy of sickness and suffering, a burden of high mortality and morbidity coupled with a poorly developed infrastructure to address the health needs of the growing population. A year before Pakistan emerged as a newly independent state carved out of British india, an extraordinary document described the poor state of health in that country.

"Environmental sanitation in the country is at a low level in most parts. Malnutrition and under-nutrition reduce the power of resistance of an appreciable section of the population and the existence of health services are altogether inadequate to meet the needs of the people while lack of general education add materially to the difficulty of overcoming the indifference and apathy with which the people tolerate the unsanitary conditions around them and the large amount of sickness that prevails".

Forward-looking in its approach, the report made some major recommendations which seem highly appropriate today, such as: "the health services should be placed as close to the people as possible in order to ensure the maximum benefit to the communities to be served" and that the doctor should be a "social physician protecting the people and guiding them to a healthier and happier life." It anticipates the focus on Primary Health Care and Health For All which were to figure in the international agenda for development in the 1970s. For carrying out its proposals for an agenda of change and re-organizing health services, the report recommended short-term programmes, which could be completed in 10 years and a more long-term programme, the objectives of which can be accomplished in fifty years. The period proposed by the report has just been completed and it provides a perspective for looking at health-related development in Pakistan.

Fifty years after independence, the Bhore Committee Report still reads more or less like a description of the situation today. The developments that have taken place, have still to make a dent in the conditions described by the report. Large scale changes and improvements are still awaited.

Data on the basic social and health indicators complements the still-grim overall picture. The national averages do not show the wide disparities and significant differences that exist between the provinces, districts and urban and rural differences. Children and women are the disadvantaged sections of the society and consequently bear the brunt of the heavy burden of disease and deformity. Diarrhoeal disease and its ensuring complications, such as dehydration, continues to be the major killer of children in Pakistan, accounting for nearly 48 per cent of the total deaths of children under 5 years of age in the country. It is followed closely by Acute Respiratory Diseases. Pakistan has the third largest number of reported cases of Neonatal Tetanus in the world, proportionately higher than the more populous India. Till recently, Pakistan was responsible for nearly 75 per cent cases of polio in the EMRO region of WHO. These diseases leave behind a residue of suffering and disability but are largely preventable. The vaccine which could have prevented these disease, costs no more than a few paisa but this is no consolation to the child or the family who were denied the right to immunization.

The 1996 Progress of Nations, published by UNICEF, highlighted the fact that half of the world's malnourished children are in Pakistan, India and Bangladesh, where malnutrition rates are typically twice as high as Sub-Saharan Africa. Quoting statistics from Pakistan, the report noted that in spite of improvements, 40 per cent of Pakistani children are malnourished. More girls than boys are afflicted with malnutrition and of those who survive to puberty significantly large numbers become "at risk" mothers.

The number of women in Pakistan who die while giving birth is difficult to determine. The maternal mortality in Pakistan is estimated to be somewhere in the range of 190 to 1,700 deaths per 100,000 live births, while a 1990 estimate gives the national maternal mortality rate as 340. The continuing tragedy of maternal deaths in Pakistan is brought home in the analysis by Prof. S. Jafarey and Kotejo's study of the women who were "brought dead" to one of the premier health institutions in the country. The major reasons cited by the study were delay in seeking care due to socio-cultural factors and inadequate medical services at the first-care level. These women did not come from some hard to reach corner of Balochistan, but these women lost their lives right in Karachi, literally within a stone's throw from some of the most sophisticated tertiary care hospitals in the country.

The problem of maternal mortality in Pakistan is a reflection of the generally poor health status of women's health. An overwhelming majority of women suffer from anaemia and malnutrition, both of which are worsened during pregnancy. Many women never realize their full growth potential, putting them at high risk of obstetrics difficulties. Higher fertility rates, child birth at early ages and high parity and negligent care of high risk pregnancies multiply their risks of sickness and death. (S. Mahmud and A. Aslam, Maternal Mortality in Pakistan: Policy Strategy). Death is the final outcome, but not in all cases. One quarter of all adult worn en in developing countries are affected by injuries and disabilities during pregnancy and childbirth. "Many of these injuries go unspoken and untreated, but they are painful, humiliating and permanent," according to the same report which thus identifies another major public health problem being faced by countries such as Pakistan. "This issue, fast in its conspiracy of silence is the most neglected tragedy of our times."

The large number of children and women who continue to die from preventable diseases is indicative of the low value placed by society on their lives and is a strong indictment of the health care delivery system.

Infectious diseases continue to have a field day in Pakistan. Tuberculosis remains a serious public health problem and malaria has apparently had a comeback. Cholera has re-emerged and typhoid is on the ascendant, with reports of new strains, resistant to the antibiotics in use till now. On the other end of the spectrum is the growing share of non-communicable or life-style diseases, the so-called "diseases of modernization". These include hypertension, cardio-vascular diseases, diabetes mellitus and a variety of cancers. A small-scale study (Akatsu and Aslam, JPMA, number 9, vol 46, 1996) conducted in a low income squatter settlement of Karachi documented a prevalence of 17 per cent for hypertension and 50 per cent overweight/obesity among women. In the same area, diarrhoea and other infective disorders continued to be rampant among children. Thus while a child may be dying of diarrhoea, his father may be suffering from cardio-vascular disorders. This phenomenon that different regions of the world and currently undergoing a change from a predominance of the acute infection and deficiency affecting children, to a predominance of the chronic diseases of adults in termed "the epidemiological transition." Pakistan has not moved out of a predomination of the first category of diseases and at the same time the diseases of the second category are here, thereby placing a double burden of disease and death.

Among emergent diseases, the spectre of which is already haunting Pakistani society are the dreaded killers AIDS and Hepatitis. While Hepatitis is turning out to be a much bigger killer than realized within the context of Pakistan, the actual number of AIDS cases to date is relatively smaller than some of the other countries in the region. There is no room for complacency however. It is predictable that these diseases will afflict much larger numbers of Pakistanis in the not too distant future. What makes these diseases even more dreaded is the fact that there are no large scale health education and limited surveillance.

In an area of general neglect for health, mental health represents an area of even greater neglect. Once again, the true extent of the problem is not known but newspapers often published stories giving very precise figures (ranging from 25 to 45%) of Pakistan's population which needs mental health care. Obviously, these are "guesstimates". Analyzing the global situation for mental health, Sugar and Kleinman had written that "the burden of at least certain of the more common mental illnesses in precisely those societies that possess the most seriously inadequate mental health services" and this is true for Pakistan. The system's lack of organized and prepared response to health problem is probably best illustrated by the emergence of heroin addiction in the country in the 1980s. It reached epidemic proportions when the number of heroin addicts increased by 50 per cent from 1984 to 1986. It is estimated to be around 3 million now. The addict population in the country may have reached a plateau now but there is no systematic approach of dealing with the problem other than isolating the addict and recently one is beginning to hear of bumper crops of poppy across the border in Afghanistan. But is the health care delivery system watching? The answer is likely to be in the negative.

Health Care Delivery System

"Any discussion of a health system must attempt to understand two major phenomenon - on one hand, the death conditions (or needs) of the population, on the other, the response that a society organizes to deal with those conditions," wrote Julio Frenk, Mexico's distinguished public health scientists, and considering this perspective, the disease profile of the country needs to be seen in the light of the health care delivery system as well as the public policies that have guided (or failed to guide!) its evolution. The First and Second National Health Conferences were convened by the District General Health in 1947 and 1951 where programmatic recommendations were made. As the First Five Year Plan unfolded, 6 medical colleges were established in West Pakistan and 6 in what was then East Pakistan. Till recently, opening of medical colleges' was seen as the simple solution for the health needs in the country. A curious result is that greater efforts are still required to orient the curriculum towards the health needs of the population and in a country where 60 million people do not have access to medical care, there are thousands of unemployed doctors. The opening of medical colleges in the private sector has on one hand created isolated islands of excellence and on the other hand, led to fraud and cheating.

In 1959 a Comprehensive Rural Health Programme was launched with the intention of linking the rural population with District Hospitals through a network of Rural Health Centres and Taluka Hospitals. In 1973, the Health Guards Project was launched under the Plan for Rural Health in the Northern Areas. In 1997, the Basic Health Services Programme was launched with the financial support of the USAID. There have been a number of schemes and projects aimed at improving the health conditions and provision of services to the under-served population, but with variable results. In terms of physical infrastructure, a network of Basic Health Units, Rural Health Centres and Taluka Hospitals has been established in the public sector, but the quality of services is variable. It is estimated that the utilization rate of these facilities is not more than 20 per cent. The private sector has thrived and one now hears of proposals to privatise BHUs and other health facilities, based upon the assumption that people are willing to pay for services if quality can be ensured. However, public sector services should be determined by the concepts of equity and social justice and not simply willingness to pay. In his book Political Economy of Health in Pakistan Zaidi pronounces a seemingly harsh verdict on the country's health care delivery system, calling it "highly inequitable, Western oriented, curative care model which certainly does not fulfil the requirements of a very great majority of the people of Pakistan." It would be hard to refute this verdict but one could place it alongside the developments that have taken place and which give reason for a cautious hope. Infant Mortality Rate has declined substantially in three decades and life expectancy has increased from 43 in 1960 to 62 in 1993.

Many of these changes can be attributed to naturally occurring secular tends rather than as a result of concerted programmatic action. However, some of the current programmes and activities need to be considered. Under the Rs. 240 billion Social Action Programme, there is increased allocation for health in public sector funding. The Prime Minister's Lady Health Workers Programme for Family Planning and Primary Health Care, the most ambitious programme of its kind ever launched in the country, which will eventually mobilize a task force of a million workers. The Expanded Programme of Immunization, which started registering a decline in its coverage after an all time high in 1990, is concentrating on "high risk" areas for reaching the global goal of neonatal tetanus elimination. The National Immunization Days against polio have been successful in creating mass awareness. To combat Iodine Deficiency Disease, Universal Salt Iodization has been accepted by the government and some progress made but the problem of macronutrient deficiencies, specially iron deficiency anaemia, need to be addressed. There is still a large agenda of unfinished business.

The National Health Policy formulated in 1990 stated: "the high infant mortality, the heavy toll by infectious diseases and the abject poverty of Pakistan's majority population with all its frightful consequences in physical deprivation, emotional instabilities and social handicaps should receive our immediate attention. It must also be recognized that there are historical reasons for this state of affairs. They range from culturally accepted neglect of women and children to wrong perspectives on development, most of which are easily avoidable." The document identified the contributory factors as follows: "poverty, high levels of population growth, rapid urbanisation, inadequate social support, poor quality of information and travel systems, lack of opportunities in rural areas, and infectious and deficiency diseases." What is striking is the close resemblance of the description to the one in the Bhore Committee Report. The resemblance seems ironical. Fifty years and a new country later, the system is still sick.

We are constantly being told about the national ambition to be an Asian Tiger. But this will not be achieved by foreign investment and economic growth alone. An unhealthy tiger is little more than a paper tiger.

Health Facilities in Pakistan

1993-94 1994-95 1995-96 1996-97

Hospital (Nos.) 799 822 827 830

Dispensaries (Nos.) 4,206 4,280 4,253 4,250

Maternity and Child
Welfare Centre (Nos.) (*)849 (*)853 (*)859 869

Beds in Hospitals
and Dispensaries 80,047 84,883 85,805 86,921

Doctors 63,009 66,199 69,691 74,229

Dentists 2,402 2,590 2,751 2,938

Nurses 20,641 21,419 22,291 22,810

Mid Wives 18,641 19,759 20,910 21,304

Lady Health Visitors 3,3920 4,107 4,185 4,250

POPULATION PER:

- Hospital Beds 1,555 1,510 1,492 1,541
- Doctors 1,919 1,880 1,837 1,773
- Dentist 50,341 48,046 46,498 44,803

EXPENDITURE ON HEALTH: (Rs. in million)

- Development 3,511 3,598 5,7412 6,485
- Non-Development 7,680 8,501 10,613 11,857

(*) The decrease in MCH since 1993 as against last year is due
to exclusion/sparation of family welfare centres from MCH structure
in NEFP.

Source: Economic Survey, 1996-97.

(Dr. Asif Aslam, a Public Health Physician. educated at Dow Medical College and Harvard, has been associated with The Aga Khan University Hospital and the International Commission for Health Research).

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