Public Health Crisis: A Cry for Reforms
Multiple crises in Pakistan feed into each other – governance, politics, economics, essential services – all ultimately manifesting in the quality of life of the people.
At a conceptual level, things are not very complicated. Increasingly, the recognition and expression of the dire state of lack of human development in Pakistan is resonating in important national conversations with reference to our persistently low rankings on human development and human capital indices. The first National Security Policy of Pakistan[1], December 2021, included human security and human health as important dimensions of national security. The titles of three recent national conferences in Islamabad reflect the underlying desperation for reforms. World Bank and the Pakistan Institute of Development Economics convened a national dialogue titled ‘Reforms for a Brighter Future: Time to Decide — A Conversation on Pakistan’s Development Priorities’. The first plenary discussion in this conference was on stunting. Margalla Dialogue, 2023, an annual event organised by Islamabad Policy Research Institute had a dedicated session on ‘Non-Traditional Security Mosaic of Pakistan,’ which discussed the deteriorating situation of health and education in the context of national security. The title of the recently concluded 26th annual Sustainable Development Conference by Sustainable Development Policy Institute was, ‘Light at the End of the Tunnel: Hope in the times of Despair’. The conference had special sessions on health related issues.
These discussions are now becoming sharper and louder. Elite capture, as a root cause, is inevitably mentioned in these conversations which at some point take a turn towards the ‘reform versus revolution’ debate. Things on ground remain unchanged. The reason is that despite the simplicity of moral and economic arguments on investing more and better on health and education of the people, neither of these are becoming fiscal priorities – nor is the status quo changing.
In the case of health, due to chronic policy neglect, lack of financial commitment, lopsided priorities and unattended inefficiencies, we have finally landed in a public health crisis situation which is not being addressed with the sense of urgency it demands.
Our national health indicators are now amongst the worst in the world. The dubious distinctions include highest population growth rate and total fertility rate in South Asia; with the latter remaining almost unchanged in last 15 years[2]. Despite this, 4 out of 9 million annual pregnancies are unwanted and are largely due to lack of information and availability of modern contraceptives. Our neonatal mortality rate is the second highest in the world, only after Lesotho, a country in Sub-Saharan Africa[3]. The same rate in Balochistan is the highest in the world, i.e. 63 per 1000 live births[4]. 42% of women between ages 15-49 suffer from iron deficiency anemia and they give birth to underweight children, many suffering from postpartum hemorrhage[5]. 37.6% children under the age of 5 are stunted, physically and mentally, due to malnutrition[6]. If stunting is not addressed during the first 1000 days of life it becomes an irreversible phenomenon. These children then remain physically weak and have low IQs. Imagine, nearly 40% of the next generation potentially in this state – not properly educated, unhealthy, non-productive and ultimately dependent on the economy instead of contributing to it.
There are only two countries in the world where transmission of wild polio virus has not been completely disrupted, i.e. Pakistan and Afghanistan, and the virus continues to cripple our children. The prospect of polio eradication seems to be slipping further away with the recent upsurge in cases. In our neighbourhood, Iran eradicated polio in 2004 and India completed the task in 2014. Pakistan ranks third in the world for having the highest number of unvaccinated children. 23.5% of our children are not fully vaccinated against protection from common infectious diseases like diphtheria, pertussis, tetanus, etc[7].
We have the world’s largest population of people, around 10 million, living with Hepatitis C[8] and we bear the 5th largest burden of tuberculosis[9]. Pakistan is also the country with the highest rate of increase in number of new HIV cases in Asia and Pacific after the Philippines, i.e. more than 80% increase between 2010 and 2020.
In terms of non-communicable diseases, Pakistan has an epidemic of Type II diabetes with 33 million people suffering, i.e. every 4th adult above the age of 20 years is diabetic[10] and 33% of our adult population above the age of 45 has high blood pressure.
The mental health issues are on the rise and most ignored. Around 90% of those needing mental healthcare do not have access, every fourth mother experiences perinatal depression and every fifth child in school has been found to have some kind of emotional or behavioural problem. 23 million children out of school, the highest in the world, is another matter.
A step back from the diseases, the risks to health – which cause these diseases – are ubiquitous and on the rise. Access to proper nutrition, safe drinking water and clean air: to name a few. We have serious problems in all these and other determinants of health. Among environmental determinants of health, as an example, Pakistan has become the fourth most polluted country in the world and Lahore now has the distinction of being the most air-polluted city on the planet Earth. Among behavioural determinants, prevalence of tobacco is very high in Pakistan. We are among the top 15 countries in the world with widespread tobacco consumption, i.e. 19.1% of our population constitutes smokers, leading to high rates of tobacco-related health issues.
Most of this burden of disease and risks are preventable if we can establish a quality primary healthcare (PHC) system in the country. However, our healthcare system favours big hospitals in big cities and with little expending on primary healthcare through PHC facilities in semi-urban and rural areas. The healthcare indicators mentioned above cannot change if we just continue to focus on big hospitals. Preventive, promotive and rehabilitative healthcare takes place most effectively closer to the people. The healthcare system in Pakistan is not planned and organised to serve people through PHC close to them. The education and training of health workforce, to start with, is not PHC oriented. We do not make it attractive to the doctors and other health workers to serve at the PHC level.
Pakistan is amongst the lowest spenders on health and that spending is also lopsided and fraught with inefficiencies. One way of looking at it is that Pakistan has increased its health financing from 0.6% in 2010-11 to 1.4% in 2020-21. A closer look reveals the real problems. High-Level Taskforce on Innovative International Financing for Health Systems stipulates a public sector spending of USD 86 per person. Total health expenditure in Pakistan is USD 45 per capita out of which only USD 14 is spent by the government on each citizen annually whereas the citizens themselves spend USD 28 (private-sector spending) and a mere USD 3 comes from external sources. Around 70% of the government health budget is spent on tertiary level hospitals and only 30% is spent on PHC. High out of pocket health expenditure is catastrophic and impoverishing. Health insurance through government financing (Sehat Sahulat Program) is a great relief for the poor but is unfortunately limited only to hospitalisations.
Current life expectancy in Pakistan is 67.7 years. 149 countries in the world have higher life expectancy than us including many poor African countries. An average Pakistani lives 17.3 years less than the average citizen in Hong Kong, currently boasting the highest life expectancy in the world – i.e. 85.2 years. An average Pakistani’s lifespan is almost 10 years less than a Sri Lankan, 9 years less than an Iranian, 7 years less than a Chinese and 5 years less than a Bangladeshi and a Vietnamese.
Why we live less, and worse qualitatively? The tragic answer: as a State, we have not prioritised the health of the people.
The public health crisis in Pakistan is a crying call for fundamental reforms.
The author is a former SAPM on health, professor of health systems at Shifa Tameer-i-Millat University and WHO adviser on UHC. He may be reached via email at [email protected].
[1] National Security Policy of Pakistan, National Security Division, Government of Pakistan, 2021. www.nsd.gov.pk
[2] Zeba Sattar, Demographic laggards, 8 June, 2023, Dawn, Pakistan. https://www.dawn.com/news/1758597/demographic-laggards
[3] The World Bank Date: https://data.worldbank.org/indicator/SH.DYN.NMRT?locations=PK
[4] Kumar V, Ali BS, Choudry E, Khan S, Baig K, Durrani NUR, Ali SR. Quality of Neonatal Care: A Health Facility Assessment in Balochistan Province, Pakistan. Cureus. 2022 Mar 1;14(3):e22744. doi: 10.7759/cureus.22744. PMID: 35386481; PMCID: PMC8970319.
[5] National Nutritional Survey of Pakistan, 2018, Key Findings Report, Nutrition Wing, Ministry of National Health, Services, Regulations and Coordination
[6] Saving Children from Stunting: https://www.unicef.org/pakistan/stories/saving-children-stunting#:~:text=In%20Pakistan%2C%2038%20percent%20of%20the%20children%20under,the%20children%20-%20and%20the%20number%20is%20increasing.
[7] Hussain I, Khan A, Rhoda DA, Ahmed I, Umer M, Ansari U, Shah MA, Yunus S, Brustrom J, Oelrichs R, Soofi SB, Bhutta ZA. Routine Immunization Coverage and Immunization Card Retention in Pakistan: Results From a Cross-sectional National Survey. Pediatr Infect Dis J. 2023 Mar 1;42(3):260-270. doi: 10.1097/INF.0000000000003804. Epub 2023 Jan 2. PMID: 36728580; PMCID: PMC9935567.
[8] Al Kanaani Z, Mahmud S, Kouyoumjian SP, Abu-Raddad LJ. The epidemiology of hepatitis C virus in Pakistan: systematic review and meta-analyses. R Soc Open Sci. 2018 Apr 11;5(4):180257. doi: 10.1098/rsos.180257. PMID: 29765698; PMCID: PMC5936963.
[9] WHO EMRO | Tuberculosis | Programmes | Pakistan
[10] Sun H Saeedi P Karuranga S et al.IDF Diabetes Atlas: global, regional and country-level diabetes prevalence estimates for 2021 and projections for 2045. Diabetes Res Clin Pract. 2022; 183109119 Diabetes in Pakistan: addressing the crisis – The Lancet Diabetes & Endocrinology
