InternationalNationalVolume 12 Issue # 13

An ailing system

The first global assessment of the United Nations’ health-related Sustainable Development Goals (SDGs) in 188 countries, The Global Burden of Disease Study, paints a gloomy picture of the health situation around the world. Launched at a special event at the United Nations recently, the analysis assesses countries by creating an overall index score on a scale of zero to 100. Pakistan, ranked at 149, shares the score of 38 with Bangladesh and Mauritania — six places behind India and way behind Iran.
For ranking purpose, countries were divided into five categories, based on a combination of education, fertility and income per capita. This new categorisation went beyond the historical “developed” vs “developing” or economic divisions, based solely on income. The researchers noted that the gains need to be sustained, and in many cases accelerated, to achieve the ambitious SDG targets. The findings also highlighted the importance of income, education and birth rates as drivers of health improvement.

The proportion of countries that have accomplished individual targets varies greatly. For example, more than 60% of the 188 countries studied showed maternal mortality rates below 70 deaths per 100,000 live births, effectively hitting the SDG target. In contrast, no nation has reached the objective to end childhood obesity or to fully eliminate infectious diseases. The analysis shows that expanded health coverage, greater access to family planning, and fewer deaths of newborns and children under the age of five, are among the several health improvements contributing to the progress toward achieving the SDGs. However, hepatitis B, childhood obesity, violence and alcohol consumption have worsened.
These analyses are critically important for Pakistan, where limited data make the transition from Millenium Development Goals (MDGs) to the SDGs even more challenging. The performance of the health sector in Pakistan has always been below par. Over the years, the public health care system has deteriorated beyond repair. The health care system in Pakistan is at the cusp of complete collapse, which is evident from the fact that there are 5,499 dispensaries, 5,438 basic health units, 669 rural health centres, 671 mother and child health centres, and 334 tuberculosis centres in the country catering to a population of about 200 million.

Due to the negligence of successive governments, lack of investment and rising poverty over the last few decades, public health services have seen a serious decline. The key issue is that the government spending in the healthcare sector is not only small, but the growth in annual spending is decreasing every year. Pakistan failed to achieve its health care targets under Millennium Development Goals (MDGs), as neither federal nor provincial governments have treated the health sector as one of their top priorities. According to the World Bank, the minimum per capita spending on essential health services package is at least $44, but Pakistan’s per capita spending on health care stands at $37.
After the 18th amendment to the constitution, the health sector has been devolved to the provinces, but the distribution of responsibilities and sources of revenue generation remains still an issue. By the federal government’s own admission, public health spending provides valuable insight into a country’s progress because better health status is described as an indicator of the economic success of the nation. However, most indicators show a declining trend in the health sector which received only 0.45 percent of GDP in FY2016. This amount is close to what the sector received in FY2014-15 when it stood at 0.42 percent of GDP. The overall health spending at the federal level decreased to Rs15.3 billion in FY 2015-16 from Rs22.4 billion in the previous financial year.

Some time back, federal and provincial governments agreed on a common National Health Vision (NHV) for the entire country. The NHV will primarily focus on improving universal access to essential health services. It hopes to bring the country’s provincial and federal health policy frameworks in line with international health treaties to which Pakistan is a signatory. The policy was developed with the participation of stakeholders from across the country. The policy has been divided along eight thematic areas in the health sector, consisting of six building blocks that the government will focus on to ensure that the provision of health services becomes more universal. It also focuses on providing a monitoring and evaluation mechanism to make sure that the progress on the plan is presented to the parliament on an annual basis.
Without doubt, the National Health Vision is a move in the right direction. Overhauling the state-owned health sector not only requires that health be put at the top of the priority list, but increased funding, efficient cross-sector linkages and medical training are also imperative. A multilateral approach focusing on primary health, disease prevention, universal coverage and service monitoring could go a long in making the NHV a reality .The decision to increase spending from the current 0.6 percent to 3 percent by 2025 will greatly benefit the health care system, though more money is not the only solution. When strategising, the government must know that poverty results in poor health conditions, including communicable diseases, maternal health and malnutrition.

Investment in preventive health breaks the cycle of poor health and poverty. At present, government-funded medical facilities cover only part of the population’s demands because few offer specialised care. This has led to the mushrooming of an unregulated private sector with disparate services and prices. If hardly 20 percent of the population uses primary healthcare systems, then coverage and functionality are in need of urgent improvement.
In the federal budget for the year 2016-17, the finance minister had spoken at length about the health insurance plan and argued that during 2015-18, close to Rs9 billion in premium will be paid through this scheme. The government has now launched the Prime Minister’s Health Insurance Programme to provide free-of-cost medical treatment facilities. According to the State Life Insurance Corporation of Pakistan, which is managing the programme, as many as 118,585 families had been registered under the insurance scheme until April 2016.

The health system in Pakistan is faced with multiple challenges in the areas of governance, finances, service delivery, human resources development, introduction of new technologies and coping with the huge burden of supplies, specially medicines. Apart from communicable diseases, non-communicable diseases also contribute to public health problems. There is a chronic shortage of medical and paramedical staff at all levels. Some of the available staff lack commitment and dedication. Corruption is also a major challenge for health care system, which not only means absenteeism from work but also includes unethical behaviour and malpractices affecting the welfare of patients. To put in place a sustainable health system, it is important to develop the infrastructure, ensure regular funding for running activities and supplies and increased investment in human resource development. There is an urgent need for reforms at the community level in order to modify the health care system according to modern needs and requirements, focusing mainly on primary health care.