Tuesday 19 February 2013

Public Health Care in Pakistan: A basket case

(Originally Published in two parts in The News as "Our Sickly Health Care" on February 7 and February 8 2013)

"The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being"
according to the constitution of World Health Organization.
The constitution of Pakistan guarantees basic rights and liberties to all citizens of the state. These rights derive from fundamental principles of justice in accordance with which the State of Pakistan assumes the sole monopoly of power over its citizens. To provide health facilities to the citizenzs, there is a Universal Health Care system in Pakistan. This means that any citizen of Pakistan can get treatment at public sector health care facilities in the country. Pakistan has a wide network of healthcare infrastructure, including 919 hospitals, 5334 Basic Health Units (BHUs) and Sub-Health Centres, 560 Rural Health Centres (RHCs), 4712 Dispensaries, 905 Maternal and Child Health (MCH) Centres and 288 Tuberculosis Centres. This system is supposed to cater to a population of around 190 million people.

Thus, one doctor at a public hospital is supposed to cater to about 1724 people, while 1504 people have to vie for a single bed at a public hospital. In a physician per 1000 people statistic, Pakistan ranks 120th among 200 countries, with only India, Iran and Egypt among developing nations below us.

Pakistan is among the only three countries left in the world with Polio Virus infection, the other two being Afghanistan and Nigeria. Recent reports indicate that Karachi, Peshawar and Hyderabad,Lahore and Rawalpindi have turned ‘polio-endemic’ due to continuous detection of the wild poliovirus virus type-1 in the sewage samples collected from there. There are more than a million people in Pakistan have Chronic Liver Disease while 10% of the population has had exposure to Hepatitis B and C viruses. As many as 1.2 million people die of waterborne diseases in Pakistan every year, of them 250,000 are children under the age of five years. In a recent meeting organized by a public health research and consultancy firm, 54% of the most serious crises and shocks Pakistan has suffered in the last three years have been health-related as compared to only 3% that have been law and order related.

We have had brushes with Widespread Dengue Virus Infection, the PIC(Punjab Institute of Cardiology)-Syndrome outbreak, Naegleria Infection in Karachi and the very recent Cough Syrup-controversy. To quote a report by Pakistan Institute of Development Economics,
“Pakistan’s health care system is inadequate, inefficient, and expensive; and comprises an under-funded and inefficient public sector along with a mixed, expensive and unregulated private sector. These poor conditions in the health sector may be attributed to a number of factors like poverty, malnutrition, unequal access to health facilities, inadequate allocation for health, and high population growth and infant mortality.”

There is acute shortage of data for health indicators in Pakistan. Health, is not a priroity of either the Government, or the people, until an emergency strikes. Every new government has brought in new health policies but implementation of these policies has not been undertaken over time. Take the case of Punjab. It is the most populated province of Punjab. There has been no Health Minister for the last 5 years and the Chief Minister has kept the portfolio with himself. The current government has opened medical colleges in almost all major cities of Punjab over the last 4 years. The lack of planning is apparent in this case as no new teaching hospital has been established and retaliatory shelving of plans by the previous government has affected the system. Without proper teaching hospitals, medical students graduating from newer colleges will have to move to other cities for getting better exposure to clinical training. The last teaching hospital established in Punjab was Jinnah Hospital, in Lahore, in the mid-90s.  Regarding retaliatory politics, the half-complete building of Wazirabad Institute of Cardiology is a living testament.

Started on the orders of the previous Chief Minister, this project aimed at catering to cardiac patients between Lahore and Rawalpindi and adjoining areas. At present, if a person needs cardiac care in Gujranwala/Gujrat/Jhelum area, he/she needs to visit either Lahore or Rawalpidni due to lack of any facilities nearby. Time, though is a crucial matters in cases of Heart disease and an early detection can significantly improve chances of Improvement. Patients are brought from all over northern part of Punjab to Lahore because of Lahore-centric health spending. There are 17 medical colleges in Lahore, compared to 17 in the rest of the province. For about 600 burn patients annually, there are a grand total of THREE specialized burn centers in Punjab. Similarly, only 155 mechanical ventilators are available in Lahore’s public hospitals for a patient load of more than 5 hundred thousand patients every month. 

Tubeculosis, Hepatitis, Cholera, Malnutrition,Polio and recently, Measles, are some of the major problems being faced by the Public health providers. With the advent of Breaking News culture, any issue deemed imprtant by the media becomes important, public health almost never makes the cut, unless there is significant panic, as in cases of Dengue, PIC-syndrome and Cough Syrup-controversy. High mortality rates don’t bring high ratings, thus no need to focus on the isssue, let the children die. Newborns only matter when bitten by mice etc, that sells. The dismal condition of public health infrastructure has given rise to a popular phenomenon in Pakistan; People taking up things in their own hands. We required a public ambulance service, Cue Edhi and Cheepa. We needed good schools and Universities; Enter Private Schools and Universities. Similarly, to fill the huge void of public health, private entities and charity based organization stepped in. Currently, almost 80% of health sector in Pakistan is based in Private sector.

For a self-respecting middle class Pakistani, visiting a public sector hospital is nothing less than a nightmare. Due to over-burden of patient load, resources dry up fast. Data collected by the author for one particular ward at a teaching hospital in Lahore revealed that in a duration of 24 hours, around 700 patients visited the medical emergency of the hospital. There were only 45 beds available in that particular ward. At the end of 24 hours, 60 patients had been admitted, resulting in patients having to share beds in majority of cases. There is acute shortage of beds in teaching hospitals and there are no plans on the horizon till now that anything is going to be done in this regard. According to figures from last budget, Punjab Government has allocated a spending of Rs 120 for every citizen of Punjab. That is not sufficient even if you want 2 surgical sutures.!!

There is an overall sense of pessimism in the Public Hospitals, which ultimately leads to the exodus of doctors to greener pastures. This is just the tip of the iceburg. All doctors are not god-fearing, messianic figures either. A lot of senior doctors practice twice a day; spending morning in government hospitals and evenings at private clinics. Then there is the issue of equipments and their effective running. Two months ago, the X-ray machine at the largest hospital of the Province was out of order, and remained like that for at least two weeks. No heads rolled. No reporting in the media. Situation is even worse in other provinces. There are hardly any specialized centers in Balochistan or even Khyber Pakhtunkhwa(excluding Peshawar) or Gilgit Baltistan. 

It is the first law of Health Economics that 
“ Increased Spending on health leads to increase in per capita GDP”. Currently less than 2% budget is allocated for Health Sector and even with this pittance, the behemoth of public health care system is functioning admist crises. The first and foremost solution to the numerous problems is presence of political will to spend more money on healthcare. Until that will is mustered, there is scant chance of improvement in the system.

Furthermore, there are significant Problems concerning public health both at the policy and implementation level, especially after the devolution of Health Ministry to Provinces. Spending has to be increased, population explosion has to be halted, Long term policies have to adopted to increase the outreach of public sector healthcare, private sector needs to be regulated, more Teaching hospitals and specialized centres need to be established in areas like FATA, Balochistan, Southern Punjab and Gilgit Baltistan.Our State has failed in providing the citizens good health care and it  is affecting the whole economy. Media and civil society have an increased role to play in this regard, because of negligent behaviour of the state. One of the tenets of the doctors’ movement has been increased spending on public hospitals and decrease in VIP protocol patients. Very recently, category for “poor” patients was shelved by the administration at Punjab Institute of Cardiology and no one has taken any notice of that.

It should not be forgotten that a state that absolves itself of its responsibilities, is paving way for its own downfall. Spending public money on flyovers, foreign visits and security guards is not going to solve the problems of health and education in this country.


    I really appreciate to Pakistani Doctors they protect to Pakistani nation DENGUE favor i really proud at ....

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