The health sector in Pakistan has been under perpetual crisis since long. The neglect of those at the helm of affairs can be seen in the fact that Pakistan is among the four countries in the world – others being Cameron, Laos and Nigeria – having lowest percentage of GDP spending on health. Even the war-torn Afghanistan was spending more on health by the year 2014 as compared with Pakistan. The health indicators in Pakistan further suggest that ineffective healthcare facilities are one of the greatest adversities being faced by the Pakistanis. Moreover, recent emergence of the case of putting fake stents in heart patients that also attracted a suo motu notice by the Chief Justice of Pakistan shows once again that even this vital sector is not spared of the incompetence and neglect that befall most government departments.
It is heart-wrenching to note that the health sector in Pakistan is among those that remain most neglected by the government. Health is a fundamental right for people and is considered a paramount component of human well-being but the plight of this sector keeps on growing. Pakistani government’s apathy toward this sector can be seen from the budgetary allocation for health in the Federal Budget 2016-17 according to which a total allocation of Rs 12,108 million has been made under the head of Health Affairs and Services and out of which only Rs 418 million have been allocated to Public Health Services. Moreover, another instance of this unending apathy is that the government announced a much-needed ‘health policy’ after 15 years of controversies over health issues and disagreements over the regulation of health departments
The result of this apathy is appalling health indicators. The infant mortality rate in Pakistan is 66 per 1,000 births, compared to 38 in India and eight in Sri Lanka. Life expectancy in Pakistan for women is 67 years, as compared to 73 in Bangladesh and 78 in Thailand. The maternal mortality rate in Pakistan is 170 per 100,000 live births, in contrast to 30 in Sri Lanka and 20 in Thailand.
The indifference of Pakistan’s government to health is reflected in the fact that Pakistan spends a mere 0.9pc of its GDP on health. Only two countries, the Democratic Republic of Congo and Bangladesh, have a lower ratio of GDP to health spending.
Another indication of the government’s neglect is the fact that public expenditure on health accounts for a little over one-third of Pakistan’s total health expenditure. Pakistan’s citizens rely heavily on private healthcare, which they avail primarily through out-of-pocket payments. This is in stark contrast not only to the developed West, but also to developing countries such as Thailand and Sri Lanka, where public expenditure accounts for most of health spending. The poor quality of government-provided health services in Pakistan is the major reason behind the large role played by the private sector in healthcare.
Behind the dismal numbers lie heartbreaking stories of lives ruined and cut short due to the unavailability of affordable and quality healthcare. An unhealthy population with severely diminished capabilities cannot substantially contribute to the economy. Health indicators suggest that it is the lack of accessible healthcare — not terrorism, drones or the energy crisis — that is the greatest adversity facing Pakistan. And although healthcare is certainly linked to problems of corruption and security, there is no reason why healthcare should not be made an immediate priority, rather than placed on the back burner of policy discourse.
The fact that Pakistan is a developing economy with resource limitations is not an excuse when we look to other low-income countries that have made great strides in healthcare in the last few decades. The experiences of these countries provide illuminating lessons that should be applied in Pakistan.
Thailand and Mexico are examples of two developing countries that have made political commitments towards universal healthcare with very encouraging results. In 2001, the Thai government introduced a ’30-baht universal coverage scheme’ that covered the entire population with a guarantee that a patient would not have to pay more than 30 baht per visit for medical care.
While health indicators in India as a whole are lamentable, some states such as Tamil Nadu perform remarkably well. For example, Tamil Nadu’s infant mortality rate is 22 per 1,000 births and maternal mortality is 97 per 100,000 births, significantly better than many other states in India (and all provinces of Pakistan).
A distinguishing feature of Tamil Nadu is the extent to which its citizens actively lobby public officials for the provision of health and other public services. This culture of protest, studied closely by researchers such as Vivek Srinavasan, involves regular activism on the part of the public to ensure that government-run health facilities and health programmes are functional and accountable.
At least two lessons may be drawn from the experiences of other countries that excel in the provision of healthcare. Firstly, government-supported universal healthcare is attainable and affordable, even in low-income countries, so long as it is made a political priority. Countries such as Thailand and Mexico have met the healthcare needs of large swathes of their populations by improving public health services and providing public insurance schemes.
Secondly, an informed and activist public can play a crucial role in mobilising public health systems to serve the needs of the population. When healthcare systems are transparent and accountable, citizen advocacy can influence government policy and healthcare governance with positive results.
In Pakistan, implementation of health policies devolved to the provinces in 2010 after the 18th Amendment to the Constitution. In theory, this should create new opportunities for public engagement with provincial and local government officials for the provision of public health services. In reality, however, provinces are yet to realise the fruits of devolution.
A Note on National Health Vision
The national Health Vision document provides a sector-wide strategic direction and a strong resonance on governance, but intentionally stops short of providing recipes and targets, which are left for contextualisation and consultation with the provinces. Overarching values are transformation and change, equity, and resilience and accountability. These are translated into key policy directions, such as better use of existing funds, investing funds for social protection, performance accountability of government services, joint production of key targets with the private sector, regulation, producing human resources for rural health markets, and standardised, quality services beginning with the primary health sector.
Nonetheless, there is little cause for complacency. Pakistan has a history of producing policy documents that are rarely implemented. The greatest challenge will be federal-provincial dynamics, which has suffered since devolution from many unresolved issues resulting in the abrupt transfer of power. The NHV provides a strategic direction for provinces to form their own policies and action plans. The federal ministry can only coordinate this process and hold back its hand from vertically implementing the NHV.
Health and SDGs
The post MDGs Development Agenda “Sustainable Development Goals” (SDGs) has come into effect on 1st January 2016. The Government of Pakistan has adopted the SDGs and its goals have been incorporated into the Vision 2025. The SDGs attempt to address all dimensions of sustainable development – economic, social and environmental – and focuses on health, education, energy, water, poverty, food and climate for promoting well-being of all to be attained by 2030. Almost all the SDGs, directly or indirectly, will contribute to health. Goal 3 of the SDGs i.e. to ensure healthy lives and promote well being for all at all levels is now being followed for achievement of the desired targets regarding communicable and non-communicable diseases.