Health Problems in Pakistan

At the time of the independence, Pakistan inherited a health care delivery system that was a heritage of grand British period. This system was in the shape of public health services and some curative services In Pakistan the planning and formulation of health policies is dealt by federal government and the provincial government has the responsibility to ensure the proper implementation of those policies. Government is investing its limited resources in the development of medical colleges and universities rather than investing in improving the quality of health care by training medical professional by introducing public health schools and technicians training institutions.

In Pakistan there is shortage of nurses, skilled midwives and birth attendants, dentists and pharmacists. The impact of government negligence towards health care on people of Pakistan can be seen from latest incident of Punjab.In Punjab many people have died after consuming harmful cough syrup and life threatening medicines. There is poor health care status of women which is a major reason of the problem of maternal mortality. A vast majority of women in the country suffer from anaemia and malnutrition which is quite dangerous during pregnancy. In the context of general neglect for health in Pakistan, the mental health represents an area of even greater neglect.

The effect of poor public health system can be seen from the ever increasing cases of diarrhea especially in children. Therefore as a child may be dying of diarrhea there is high probability that child’s father may be suffering from cardio-vascular disorders. Rich section of society has the better access to health facilities as they have more many and can afford private hospitals but poor on the other hand has no access to basic health facilities. The Government should ensure quality in delivering health services. It should provide better incentives to health professionals and should focus on designing training institutes to ensure the proper health care system in Pakistan as a healthy nation can ensure better productivity and healthy economy.

Introduction:

Access to health facilities is the basic responsibility of every citizen but unfortunately the Government of Pakistan has failed to fulfill its commitment with health sector.

Hypothesis:

“Poor Public health care has negative effects on the people of Pakistan”

Brief History of the Health Care System

At the time of the independence, Pakistan inherited a health care delivery system that was a heritage of grand British period. This system was in the shape of public health services and some curative services. It was basically designed to prevent large scale epidemic and provide medicinal services for the population in large and medium sized towns, many of which were along the lines of communication or political or strategic consequences.

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(1947-1955) during initial phase, most important foremost problem was the replacement of staff. With the support of UNICEF, BCG vaccination campaign was launched and to add more, medical schools were opened in the West Pakistan. Phase known as Five Year Plan from 1955 onwards, developmental activities were affected in phases of five year.

Throughout (1955-1960) 1st Five Year Plan six new medical colleges were made, one for women were opened in both wings, a nursing school was attached to each of these medical schools. Postgraduate institution was also established at the same time.

Throughout (1960-1965), 2nd Five Year Plan over the recommendation of a Medical Reform Commission, to cover 50000 populations by Rural Health Center scheme, two Health Technician’s Training institutes were open, a malaria eradication program and family planning program were launched.

Throughout 3rd Five Year Plan (1965-1970) in addition to extension of the abovementioned initiatives, l Tuberculosis Control Program and Small Pox eradication programs were launched and the major infrastructure of the public health care system was set up in the 1970. Launched by the World Health Organization Pakistan endorsed the “health for all by 2000” initiative.

Throughout 4th Five Year Plan (1970-1975), share of medicines was largely increased for major hospitals, generic name drug system was introduced to cut down the prices of medicines, eight publicly owned fair price drug shops were opened, three new nursing schools ,six new medical colleges , and one public health school were opened.

(1978-1983) The 5th Five Year Plan was planned for 1975-1980, but to cover the deficiencies and to make a more practical plan, the slight shift was made. Under Country Health Program (CHP), that aimed at improving planning and management of health services was done.

Throughout 6th Five Year Plan (1983-1988), government launched rural development program that provided base for Health for all by the year 2000.

Throughout 7th Five Year Plan (1988-1993), new facilities like (Basic Health Units and Rural Health Centers) were established, female medical technician school was made, and laboratory facilities with health facilities were provided. Health facilities were linked with trained paramedics and semi-skilled termed as community health workers.

(1993-1998) In 8th Five Year Plan (1993-1998), HMIS (Health management information system), SAP (Social action program), and Prime Minister Program for Family Planning and Primary Health Care were launched.

Throughout 9th Five Year Plan (1998-2003) , public private partnership and privatization of health facilities were the areas of programming, Decentralized Planning, Levying user charges for financing were made.

In latest initiatives taken by government it has planned to create Programmatic and Organizational and Management Reforms. These are to promote elimination of poverty agenda of government, under health sector reforms, devolution has acquired immediate importance and major impetus is on district health system. The Health care Policy of Pakistan considers health sector investment as a part of government’s Poverty Reduction Plan. It gives more importance to primary and secondary health services in comparison to tertiary level health services in the past. To achieve quality in health sector government is making little efforts to improve governance in health sector.

Organizational structure of public health care system

According to the constitution of Pakistan health care is mainly the responsibility of provincial governments, except in the territories administered by federal government. The planning and formulation of health policies is dealt by federal government and the provincial government has the responsibility to ensure the proper implementation of those policies. The responsibility of the implementation of some vertical programs on AIDS and malaria, and extended program of immunization rests largely with the federal Ministry of Health.

Health care sector in Pakistan consist of private and public sector. The private sector serves nearly 70% of the population, is primarily a fee for service system and covers the range of health care provision from trained allopathic physicians to faith healers operating in the informal private sector. Neither private, nor non government sectors work within a regulatory framework and very little information is available regarding the extent of human, physical, and financial resources involved.

The public sector consists of more than 10,000 health facilities ranging from Basic Health Units (BHUs) to tertiary referral canters. Currently Basic Health Unit covers around 10,000 people on the other hand the larger Rural Health Centers (RHCs) cover around 30000-450000 people. In Pakistan, Primary Health Care (PHC) units consist of both BHUs and RHCs. At sub district level the Tehsil Headquarters Hospital covers the population while the District Headquarters Hospital serves a district as its name suggests. At present there are 22 Health Systems Profile- Pakistan Regional Health Systems Observatory- EMRO 28 tertiary care facilities in Pakistan, which are mostly teaching institutions located in the major cities.

According to a study less than 30 % of the population has the access to the facilities of the PHC units and on average every person visits a PHC facility less than once a year. The reasons for their underutilization, as recognized by both the managers and consumers, are the lack of health care professionals and specially women, high rates of absenteeism, poor quality of services and inconvenient location of PHC Units. There are many organizations like the Pakistan Army, railways, departments of local government and many other independent organizations that are providing healthcare facilities to their employees and those employees form a major portion of the population.

In Pakistan the planning for health care system has three main parts which includes a formal planning which resolves around the production of 5-15 year long term plans, short-term plans (ADP) and annual recurrent budgets.

The Federal Ministry of Planning and Development which is commonly known as the Planning Commission in Pakistan is mainly responsible for long term and strategic planning of health care system and the Provincial Health Departments and the Ministry Of Health design their plans in line with the overall policies of the Planning Commission. Development of appropriate plans requires the clear knowledge and understanding of heath related issues and the needs of the society and the knowledge of indicators of social development. Evaluation of needs for health care programmes in Pakistan is usually based on the size of the population in a particular area.

Unfortunately the government does not take seriously the detailed needs of those areas. There are many flaws in the implementation of healthcare programs and there is discrimination as well on the basis of locality. In posh areas people have better health care facilities. Villages At present the public health sector generates insignificant amount of resources through token user charges.

The key source of financing of the public sector in Pakistan is the government. Through Annual Development Plans (ADPs) capital investment in the public sector is financed. The Annual Development Plans (ADPs) include external funding derived from foreign aid (overseas funding) from both bilateral and multilateral organizations. It is the responsibility of federal government to finances the development budgets of provincial governments. The provinces are independent when it comes to the allocation of funds over different sectors. As far as the non development budgets of provincial governments are concerned then those budgets are funded by provincial government revenues though the Federal Government covers existing deficits through non essential grants. Even though public sector expenditure on health has remained less than 1% of GNP for a long time, per capita health expenditures have improved a great deal in last decades.

The sum total of percentage of GNP that government spends on the healthcare in Pakistan ranges between 3 and 4 percent with 2-3 percent of GNP directed towards private healthcare.

Human Resource condition in Pakistan’s health sector:

There is a shortage of clear sustainable vision for human resource development and the federal MOH or provincial DOH does not have a unit, responsible for such an important health system function. There is gender discrimination in health sector. Females are given priority when it comes to nursing. We hardly see male nurses. Government is investing its limited resources in the development of medical colleges and universities rather than investing in improving the quality of health care by training medical professional by introducing public health schools and technicians training institutions.

Even though there is a increasing interest to address the problems in human resource in medicine in Pakistan including shortage of nurses, skilled midwives and birth attendants, dentists and pharmacists the future planning for tackling these issues of medical health concerning health professionals and their abilities in the countries is still unclear and the government is still unable to pinpoint the major areas of problem.

Recently the Government of Pakistan has started a new national program for the training of community midwives by actually investing on it. The program has been launched to address the issue of incompetent and untrained midwives which are pretty dangerous to health sector. The government has announced that the first batch of trained community midwives will be ready soon. . Many new nursing and midwifery schools have also been launched by government in some districts and provinces. There are some academic institutes that are providing post graduate training in nursing in order to relieve the disaster in nursing which is generated by limited production and external brain drain.

In the framework of health system development, there is an alarming shortage of skilled and qualified healthcare experts like human resource planners in health sector, health information experts, heath care system managers and healthcare economists. The government’s ability to train the staff members is pretty limited to non-existent in the country. Unfortunately government is unable to fully train the medical staff and is still playing with the life of people.

As far as the pre-service training of health experts is concerned conventional methods are being followed and there is a difference between educational objectives which are highlighted on hospital based care instead of addressing the needs of the communities for primitive, defensive curative and rehabilitative services. Due to many institutional ad professional reasons like lack of interest from the PM&DC the attempts to establish strong rules and approaches including COME (community oriented medical education) have not been successful in medical schools . Another reason of its failure is the weak department of public health in medical schools and lack of commitment of government and heads of medical institutes.

The Pakistan Medical and Dental Council (PM&DC) has the responsibility of registration, licensing and assessment of the medical and dental practitioners, curriculum review, evaluation and approval of educational institutions. It is also responsible for many other regulatory activities. It has proved to be inefficient in its working by issuing license to the incompetent dental and medical practitioners which are practicing in the health sector.

The role and responsibility of PM&DC is questioned by the Ministry of health as it is unable to perform its functions well. It is not fulfilling its commitment to the health sector. The ministry of health has so far not taken any corrective measures in this regard. It is just asking questions and not finding answers which should be its priority.

There is no system of structured continuous professional development and there is no way by which a medical professional is held responsible for its incompetence. Although the PM&DC has made some attempts but they have not been materialized yet. The attempts made by PM&DC have not materialized yet. There is a shortage of public health and community direction in the programs of medical and nursing schools. Graduates of these schools are not well prepared to practice in a public health care atmosphere while these needs are most important.

Some organizations and medical schools have recently started course in nursing like Aga Khan University Hospital has recently started a degree program in nursing but we all know that it operates in private sector not in public sector.

In 1990 under the Family Health Projects to develop programs a network of 4 provincial and 60 district health development centers was established for in service training of staff. These centers have not been properly institutionalized beyond their project life and seem to fade out gradually.

Homeopathic doctors and Yunani Hakims became almost non-existent under the regulation of private practitioners and different traditional categories of medical practices. Data on various categories of professionals are limited and fragmented. This situation is affected by the fact that registration is not up to date and in some cases professionals are practicing their work without being getting registered.

However Pakistan is gifted with important training and research institutions and highly qualified professionals who can add in the design and implementation of a well expressed policy and strategies for human resource development.

Young doctors Association- Punjab:

The young doctors association in Punjab has been laying great pressure over government since last year to accept their demands.

On 8th November 2012 the representatives of the Punjab government, including Adviser of the CM Salman Rafiq, chief secretary and health secretary they give surety to the YDA office-bearers that the CM would issue a notification about acceptance of demands within 48 hours,” said YDA General Council Punjab Chairman Dr. Muhammad Haroon.

He further said that the demands have been accepted by the government of the YDA regarding termination of an FIR drawn against four young doctors in the first week of July this year in Lahore during the young doctors’ strike that remained intact for 21 days.

But the doctors are again showing their stubborn and “non-professional attitude” towards ailing humanity, as they are not continuing their duties by staying away from the government hospitals across the province of Punjab including Lahore. On Friday, the third day of protest they continued to press the government to immediately release all the arrested doctors and also pull out cases registered against them regarding Gujranwala incident ( Young doctors got beaten and injured the DHQ Hospital medical superintendent, senior doctors and journalists during their protest ).

The young doctors have boycotted the out-patient departments, indoor departments and operation theatres as well as the OPD’s. However emergencies are still functional, due to these patients are suffering. This time, not only patients but senior doctors, civil society and people from other walks of life are criticizing the young doctors for their wrong approach.

They blamed the bureaucracy for playing politics with them and have asked the provincial government to stop harassing young doctors through registration of cases against them.

Punjab Government decided to suspend and transfer young doctors:

The Punjab government recently has released notifications regarding the suspension and transfer of many leaders of the Young Doctors Association (YDA). Healthcare facilities were restored in all government hospitals and the young doctors resumed their duties all over Punjab after the association gave a deadline of six days to the provincial government to accept their demands. YDA doctors have warned the provincial government that they would go on strike again if their service structure is restored.

Gujrawala incident has no justification where annoyed doctors over the arrest of the young doctors YDA leaders slammed into the office of Gujranwala District Headquarters Hospital medical superintendent and beat him up along with some journalists trying to cover the incident after that the YDA went on strike. 

The Pakistan Medical Association and the Punjab government planned some strict measures against these young doctors and they had to give up for the doctors responsible for the manhandling of the MS and the strike was brought to an end.

National Health Policy:

Health policy can be defined as the “decisions, plans, and actions that are undertaken to achieve specific health care goals within a society.”According to the World Health Organization, an explicit health policy can achieve several things: it defines a vision for the future; it outlines priorities and the expected roles of different groups; and it builds consensus and informs people.”

National Health Policy – Gillani’s views:

On 22nd April 2012 the former Prime Minister of Pakistan Syed Yusuf Raza Gilani said that the effective and sustained implementation of the National Health Policy 2010 would go a long way in meeting the Millennium Development Goals (MGDs).The National Health Policy incorporates key priorities such as family planning, maternal and child health, workforce development and meeting the Millennium Development Goals by 2015, he said while speaking at the inauguration of the newly expanded and renovated Accident and  Emergency Department of Jinnah Post Graduate Medical Centre (JPMC). The Governor Dr. Ishrat-ul- Ebad Khan, Chief Minister Syed Qaim Ali Shah, Parliamentarians, CM’s Special Assistant Waqar Mehdi, Sindh Chief Secretary Abdus Subhan Memon were also present on that occasion.

Yousuf Raza Gilani said that the National Health Policy has been formulated on the basis of recommendations by the Health Policy Task Force in consultation with all key stakeholders. He further added that the health sector has traditionally been a neglected area and it did not receive the attention it rightfully deserved. The vast vacuum existing between policy decision-making and operational levels impacted adversely upon the delivery of health related services. 

The systematic flaws of our mixed health infrastructure resulted in wastage of resources, duplication of work and inability of health institutions responsible for spearheading the reform agenda. 

The broader structural dimensions such as decentralization, efficiency, economical use of resources and mechanisms of social protection were also ignored, he remarked. He said that in 2008, he had ordered the establishment of a Health Policy Task Force to design institutional response to the problems of the health sector. 

He announced an additional grant of Rs 55 million for the remaining work of  the on- going renovation and expansion project of JPMC for taking this immense project to a logical conclusion. 

He said the abolition of the Concurrent List from the Constitution after the unanimous passage of the 18th Amendment and historic adoption of the National Finance Commission (NFC) Award has empowered the provinces politically, administratively and financially. Health and Education are now purely provincial subjects and it is for the provinces to rise to the occasion and make the difference through innovative methods of implementation of policies. 

“I would like to urge the provinces to focus on building their capacity for effective delivery of health services at the grassroots level”, Syed Yousuf Raza Gilani said. 

Stating the Quaid-e-Azam’s message at Eid-ul-Azha on October 24, 1947 the Gillani read “Let us mobilize all our resources in a systematic and organized way and tackle the grave issues that confront us with grim determination and discipline worthy of a great nation.” 

Talking about the demand of JPMC staff for maintaining the status of the hospital as an independent body under the federal government, he said that he will ask the Chairman Implementation Commission Senator Raza Rabbani to visit the federal hospitals and discuss the issues with the Chief Minister, Governor and the administration.

He appreciated the efforts and services of Executive Director JPMC Tasneem Ahsan and incharge of Emergency Department Dr. Seemi Jamali for achieving the goal of making the best and biggest A & E department in a public sector institution in this country. 

He said the Hospital has lived up to the expectations of people by responding to the health-related challenges, which should be encouraging for the management and staff of the JPMC. 

Of late, Karachi, the financial hub of Pakistan, has witnessed the recurring incidents of terrorism and terrible bomb blasts.  The Hospital and its staff have commendably responded to the challenge of tending to the injured and thus added a glowing chapter of dedicated service, he said. His final remarks were: “The people of Karachi are rightfully proud of you.”

Health Service Delivery in Pakistan:

The infrastructure of public health service delivery of Pakistan consist of 5000 basic health units, 600 rural health centres, 7500 other first-level care facilities and over 100 000 lady health workers which are providing basic health care services across the country. As far as secondary care hospitals are concerned then there are 989 hospitals, at tehsil and district levels which are responsible for the referrals.

The responsibility of provincial department of health has increases after the devolution plan in health. Extensive WHO support for capacity-building is required to ensure that the provincial health authorities can deliver at the expected level to improve health conditions, especially for population groups with the least access to health.

The role of lady health workers:

Through the deployment of 110 000 lady health workers covering almost 60% to 65% of the target population the community involvement has become a major feature of the extension of health care services to rural areas and urban slums

Government has established the lady health worker programme. The main goals of the program are enhancement of maternal, newborn and child health, provision of family planning services and the integration of other vertical health programmes.

For independent Expanded Programme on Immunization vaccinations lady health workers have been trained in selected districts

Without recognizing the importance of family planning component, increasing competencies and skills of lady health workers, increasing their knowledge about health issues, sustained logistics and more robust management oversight and support we cannot guarantee the proper performance and quality of such programs. In the context of devolution the long term commitment and honesty for better service delivery and capacity building of the lady health workers is required.

Basic health services package:

The WHO has undertaken the responsibility of development and costing of the basic health services package in Pakistan. The goal of which was to implement consistent integrated chief health care in first-level care facilities. This goal was associated to the draft of national health policy (2010) for national implementation connected to overall approval of the policy.

The concept of basic health services package has been implemented in Punjab as minimum service delivery standards. Nevertheless, Government needs to determine the requirements for the implementation of the basic health services package, including a costing examination. This may also be a supporter for development of the total funding distribution of health in Pakistan.

Private health care:

Through a network of private providers the private health care sector accounts for 70%-80% of health care delivery. On the other hand deficiency of standards and quality of care at all levels of service delivery and the lack of regulation compromise health care delivery outcomes in this sector.

Effects of poor public health system on the people of Pakistan:

The lack of information is one factor that hinders the Poor people’s use of health services. Poor access to social networks, inadequate services, and inability to pay are some of the other factors. Due to poverty and lack of awareness the lower income group of the society is compelled adopt inappropriate health seeking behaviors such as selecting a low standard hospital, untrained health care provider, self medication or even the discontinuation of treatment because of their low salaries and shortage of money. These actions worsen the financial and health status of the patient, thus creating a vicious cycle. 

To afford the treatment such as major surgeries patients are forced to take loans. They adopt ex-post strategies. These are strategies to deal with the financial consequences of ill health including the costs of healthcare and loss of wage and production due to illness. Some people sell productive assets. These strategies reduce the saving capacity of individuals. People are usually compelled to sell their properties, cars and other furniture to save the lives of their loved ones as the quality treatment is pretty expensive. If you want a good doctor then you will have to pay a fortune for it.

Some effects of poor health care system in Pakistan on its nation are stated below:

Life threatening Drugs:

The impact of government negligence towards health care on people of Pakistan can be seen from latest incident of Punjab.

In Punjab 36 people have died so far, 25 of these in Gujranwala, whereas many are apparently in a very sensitive condition due to the consumption of harmful cough syrup during the last few weeks in the most populous province Punjab.   According to Medical Superintendent of District Head Quarter Hospital Dr Anwar Amanullah, 21 persons were brought from different areas who had consumed the alleged toxic cough syrup and drugs excessively. Seventeen out of 21 died including the former Councilor of Nadi Pur Town, Chaudhry Irfan.   It was the second wave of deaths from apparent cough syrup abuse since just over a month ago when up to 19 people died in Lahore.   In spite of the deaths in Lahore being highlighted by the media, the syrup was being sold without prescription at medical stores across Punjab. After drinking the syrup, the men fell unconscious and were brought to hospital. Doctors referred some of them to Mayo Hospital in Lahore.   Relatives of some of those who died alleged that many medical store owners were selling the killer syrup without asking for prescriptions.

Effect on women:

Another effect of poor condition of health sector in Pakistan is on women.

It is difficult to measure the number of women who die while giving birth in Pakistan. The maternal mortality in Pakistan is expected to be anywhere in the range of 190 to 1,700 deaths per 100,000 live births whereas 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. 

In Pakistan we can see that there is poor heath care status of women which is a major reason of the problem of maternal mortality. A vast majority of women in the country suffer from anaemia and malnutrition which is quite dangerous during pregnancy. Supplements are very expensive and the women of low income group are unable to afford it. Many women are unable to recognize never their full growth potential which puts 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). In most of the cases these kind of women die while giving birth which sometimes results in the death of new born as well. Some of the women in developing countries like Pakistan are affected by injuries and disabilities during pregnancy and childbirth. Most of these injuries go unspoken and untreated. It becomes unbearable for the women to live with such injuries as they are painful, humiliating and permanent. This results in the long t