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The Health Sector...............................................................................................................1
Introduction:.................................................................................................................. ...........2 Why Does Health Matter?............................................................................... ........................2
Pakistan’s Health Status.....................................................................................................3 Development in health sector.............................................................................................7
Two Biases: Urban and Rural class................................................................................ ........8 Is the Medical Education and Training Model Appropriate?.................... ...........................9 The Private Sector in Health Care.............................................................. ..........................10
Summarizing the Issues in Health Sector........................................................................11 References.........................................................................................................................13 Annexure...........................................................................................................................14
The Health Sector
Better health has welfare implications not only for the individual and the household they form part of, but also for the country as a whole. The government must undertake health interventions because peoples’ health status plays a crucial role in determining the social and economic development of a country. World Development Reports show that the past few decades witnessed an increase in health gains not only in the developed countries, but also in the developing countries. Yet, at the advent of 21st century, where many developing countries have achieved substantial improvements in health, the situation in Pakistan remains poor.
Why Does Health Matter?
According to the World Development Report (1993, pp.17), benefits of improved health are manifold. Broadly these can be summarized as follows: Health plays the key role in determining the human capital. Better health improves the efficiency and the productivity of the labor; ultimately contributes to the economic growth and leads to human welfare. A positive relationship exists between the public sector expenditures and the economic growth. To attain better, more skillful, efficient and productive human capital resources, governments subsidize the health care facilities for its people. Public sector pays whole or some part of the cost of utilizing health care facilities. Healthy people are better able to learn. In developing countries, where one of the major causes of low enrolment rates is child morbidity, better health can result in higher enrolment rates in schools. Low enrolment rates, especially those of females, associated with poor health reduce the gains from schooling and ability to learn. Better health and nutrition may increase labor productivity. Further, economic gains of improved health status are greater for poor people who can benefit from the use of resources otherwise inaccessible because of disease. For the economy as whole, improved health can produce savings in treatment costs by reducing the incidence of disease. In developing countries, many illnesses can be prevented through strengthening the primary health care system, and resources can be saved that otherwise have to be spent on treatment costs. For the individual household as well, improved health results in better use of resources. 2
Pakistan’s Health Status
The health status of Pakistan is characterized by a high population growth rate, high incidence of low birth-weight babies and maternal mortality. The severity of health poverty is closely reflected in the country’s poor health indicators. In 2002, infant mortality rate is 82 per thousand live births; life expectancy is 63 years. Although country’s health indicators improved over time but its pace has been very slowed (see Table 1). Maternal mortality rate is also high at 350-435 per hundred thousands births, largely because 78 percent of births take place at home, under the care of traditional birth attendants. The proportion of low birth weight babies was 25 percent; child mortality rate is 95 per thousand and proportion of under 5 malnourished children is 39; about 10 million children under five years are malnourished resulting in 61 percent being stunted, 39 percent being under weight and 9 percent being wasted. The country’s health indicators depict a dismal picture when compared with other countries at the same level of development.
The country’s health indicators are poorer than the low-income countries such as India, Bangladesh, China and Sri Lanka. The poor outcome in health sector is mainly due to the ineffective delivery of services as well as the low spending on the health sector in Pakistan, which remained very low relative to other developing countries. In addition, even this low level of spending on health sector declined from 0.8% of GNP in FY90 to 0.7 percent of GNP in FY02. Not only the spending on health sector is low but also its 3
allocation within the sector is directed to the areas that do not benefit the poor. Clearly, high priority was given to hospitals, medical colleges and curative services in urban areas, while primary healthcare and rural health service have been ignored which has led to a high rural-urban disparity in health care resulting in rapidly increasing poverty level in rural areas during the last decade .
Poverty is thus both a consequence and a cause of ill health. Illness pushes people into poverty through lost wages, high spending for disastrous illnesses and repeated treatment for other illnesses. Due to inadequate nutrition and lower immunity, poor are more susceptible to disease pushing them deeper into poverty.
A recent health survey shows that 55 percent of the poor and 65 percent of the extremely poor were ill in Pakistan. The poor quality of most government medical facilities and the lack of access by the poor forced them to go to private medical practitioners or quacks. Of the poor, on average, 54 percent go to private medical practitioners, 13.3 percent to government hospitals,8.0 percent to government dispensaries and 5.6 percent to homeopaths, hakims and others. Ironically, a large number of private allopathic medical practitioners are poorly trained and have inadequate diagnostic facilities. As a result, the poor suffer a protracted illness and get locked into a high cost source of medical treatment. Since wages are commonly low, particularly in rural areas, unskilled labor, subsistence farmers and small holders are often forced to sell their meager assets and eventually borrow money to finance the treatment of the loved ones.
Thus, the prevailing primary healthcare system in Pakistan pushes a vulnerable household into poverty and the poor households deeper into poverty. This is one of the explanations of a rapid rise in rural poverty during the 1990s (Figure 1.1).
Most of the diseases in Pakistan are caused by inadequate and contaminated sources of water. The most widespread diseases, such as typhoid, cholera, and most intestinal infection, are the result of poor water and sanitation availability. Infant mortality usually falls when adequate water supply is made available, and making sure that internal piped water is provided to the household is one of the most disorders in children. In household is one of the most effective means of lowering infant mortality and diarrhoeal disorders in children. In house holds with internal piped water, there is a decline of as much as 20 per cent in child morbidity. Hence the need for more and cleaner water and sanitation facilities if ill-health is to be reduced. Table1.2 shows that, while there has been much improvement in drinking water availability in both rural and urban areas since the 1970s, even now only half of Pakistan’s populations who live in rural areas have what is considered to be ‘safe’ drinking water. Sanitation conditions are even now almost nonexistent in rural areas. Table 1.3 shows the prevalence of disease in Pakistan and the main causes of death, and indicates clearly that most of the diseases are a result of inadequate water and sanitation facilities. However, in recent years, diseases caused by changes in demography and lifestyles are also on the increase: ‘first world’ diseases like cancer and heart disease are on the rise as living conditions and dietary standards and preferences change.
Table 1.2 Access to drinking water and sanitation facilities, 1976-2002(%) Drinking water Year Total 1976 1980 1985 1990 2002 22 31 44 52 60 Rural 11 17 25 45 53 Urban 54 68 79 80 83 Total 20 22 39 Rural 10 27 Urban 22 37 53 55 59 Sanitation
Source: Human Condition Report 2003, Islamabad,2003,p.238.
Table 1.3 Main Causes of death in Pakistan
Name of Disease Pakistan Urban areas Rural areas
All causes 100 100 100 1. Infectious and parasitic 53.84 67.64 63.07 diseases 2. Malaria 10.54 7.86 10.96 3. Congenital anomalies, 7.36 5.64 7.71 birth injury and causes of perinatal mortality 4. Tuberculosis of all forms 5.55 2.86 6.09 5. Bacillary dysentery and 2.51 2.88 2.44 amoebiasis 6. Accidents, poisoning, 1.88 1.05 3.03 and violence 7. Diseases of heart and 1.79 3.92 1.35 circulatory system 8. Peptic ulcer, appendicitis, 1.2 1.09 1.22 Intestinal obstruction and hernia 9. Diabetes mellitus 1.14 0.75 1.22 10. Complication of 1.13 1.39 1.08 pregnancy and child birth 11. Tumors 0.34 0 0.41 12. Unknown causes 2.85 4.91 2.44 Source : Zaidi, S.Akbar, The Political Economy of Health Care in Pakistan, Vanguard, Lahore, 1988, p.55.
Development in health sector
The number of hospitals has increased by two-and-a-half time’s since1955, while the number of hospital beds has increased fourfold, and the population-per-bed has fallen by about a quarter. Facilities such as Basic Health Units and Rural Health Centers, which are the primary source of contact, especially for the rural community, have increased substantially. Due to a concerted effort by the government to increase access to rural health facilities, Basic Health Units (BHUs) increased from 249 in 1971 to 5,308 in 2001, an increase of about twenty times. Likewise, Rural Health Centers (RHCs) have increased fivefold in the last twenty-five years. The desire by the government to provide a health facility in every Union Council in the country, at least on paper, may be close to being satisfied. Just as health facilities have grown, so have medical providers: from only 127 doctors in 195, there are more than 100,000 doctors registered today. There were only two dentists in the country in 1962, while there are more than 5,000 now. Secondary and tertiary-level medical staff, such as nurses, lady health visitors, (LHVs) and midvives, is extremely important in the delivery of health and medical care. The number of nurses has increased by 87 times in twenty years, midwives by 37 times, LHVs by 80 times. The population per doctor ratio fell from 75,000 people to one doctor in 1962, to only 1,880 per doctor in 1994. All these trends seem to suggest positive developments and show concerted government effort at providing health for all the people of Pakistan. Table 1.4 Medical and Health Establishments, 1955-2002
BHUS Sub-health Hospitals Dispensaries centers Maternity and child-health centers Rural health centers TB centers Total bed Population per bed
1955 1961 1971 1981 1991 2002
333 345 495 600 776 906
984 1,251 2,136 3,478 3,993 4,590
3 249 774 4,414 5,308
198 422 668 823 1,057 862
1 87 243 465 550
19.197 2,077 18 22,394 2,063 79 34,077 1,804 99 48,441 1,731 219 75,805 1,416 285 98,264 1,517
source: government of Pakistan, Pakistan Economic Survey, various years, Islamabad
Table 1.5 Population per medical facility in Pakistan, by urban and rural areas, 1988
Total Facility Number Population per facility Number Population per facility Number Population per facility Urban Rural
Hospitals All beds Doctors Nurses
602 47,412 15,500 5,100
139,172 1,767 5,405 16,427
467 38,838 13,175 -
58,011 610 1,801 -
135 8,574 2,325 -
444,837 7,004 25,829 -
source: government of Pakistan, Pakistan Economic Survey, Islamabad
Two Biases: Urban and Rural class
A cursory glance at the distribution of health facilities in Pakistan gives a starling picture: despite the fact that half of Pakistan’s population lives in rural areas, most of the medical personnel and health facilities are found in the cities. For example, 85 per cent of all practicing doctors work I the cities, which comes to a (theoretically) favorable doctorpopulation ratio of 1:1801 for the urban areas of Pakistan. The rural doctor-population ratio, on the other hand, is 1 doctor to 25,829 inhabitants. Similarly, 23 per cent of the hospitals in the country were located in rural areas and only 8,574 beds (18 per cent) were available to a population of 80 million. The reasons for such an ‘urban biases in Third World countries are numerous. Firstly, the ruling class resides in cities. This applies to agricultural societies too, where, despite a
feudal structure, a very large proportion of the landlords are an ‘absentee’ type and live in cities alongside the industrial and mercantile elite, enjoying the fruits of ‘development’. Secondly, the cities are also the seat of government in Third World countries. Along with the ruling class, the members of government, the bureaucracy, and the military have made the urban areas their homes and power bases and thus infrastructure has been developed to support them. Thirdly, organized, articulate, and politically active groups such as trade union, students, and professionals have also made their presence felt in urban areas, and have acted as pressure groups to secure their demands. Thus despite the apparent urban bias, we can conclude that irrespective of geographical location, it is social, economic, and class location which determines access to health facilities.
Is the Medical Education and Training Model Appropriate?
The purpose of medical education is to produce medical personnel who can work effectively in the existing model of health care in a country thus, the doctors produced after six or seven years of training in Pakistan are those who work best in the setting described above: one that is urban care oriented, and works in the interests of the richer inhabitants of the country. Medical students in Pakistan are taught from books written in and for the developed countries. Thus the diseases our students learn about are more specific to developed capitalist nations than to underdeveloped ones. For example, they learn the main killers, while the real situation in Pakistan is that parasitic and infectious diseases are responsible for 54 per cent for all deaths, while diseases of the rich and of western countries (heart disease and cancer) account for les than 2 per cent of deaths. The teaching methods and 9
books leave such a profound influence on the students that they begin to believe that one of the main causes of death in Pakistan is indeed cardiovascular problems. In underdeveloped countries like Pakistan, where most diseases are of communicable and preventable nature, the emphasis should be on training doctors who are well versed in primary health care techniques, yet, the course in Community Medicine in medical school is not taken very seriously by the students and teachers, who have no real community experience. Often, qualified doctors are unable to cope with simple and common problems like snake-bite. The training and practical experiences of medical students are solely dependent on their interaction with patients who come to their urban hospitalagain, a curative approach, when a preventive one may be preferable. An important outcome of this type of education and training is the ‘westernization’ of doctors. Since doctors in Pakistan are taught about ‘western diseases’, most doctors can, after some acclimatization, work easily in hospitals in the developed countries. Pakistan’s system of medical education has been a major reason for the medical ‘brain drain’ from Pakistan, with nearly 50 per cent of its doctors practicing outside the country.
The Private Sector in Health Care
As long ago as 1982, the private sector was the largest source of funds for the health sector. Of the total health expenditure that year, 58 per cent was contributed by the private sector, while 27 per cent came from the government - the rest was contributed by welfare organizations and charities. In 1982 private payments accounted for 71 per cent of the total, and the government for only 18 per cent. Government expenditure on the health sector has seldom been above 1 per cent of GNP, while private consumption expenditure on health has been double, or even three times as much. Hence, the contribution by the private sector, in terms of expenditure and resources, is quite substantial.
Summarizing the Issues in Health Sector
Over the last 57 years, there has been a considerable improvement in the distribution and availability of health services and facilities. Coverage has improved substantially, and the doctors and nurses per population ratios have also increased, and are now comparable to many middle-income economies. However, this high and growing converges not reflected in indicators of health and longevity, and many poorer countries have been able to develop better facilities, reflected in the better health status of their population. Some key issues in the health sector can be summarized as follows: 1. Poor quality of the available health services in the public and private sector. 2. A very high focus on curative, rather than preventive, health and medical care. 3. Inequitable access by geographical location, with most facilities located in urban areas. 4. Access to health facilities determined by wealth and income, with the rich having easy access to the best facilities. 5. Doctors being trained who are not aware of, or functional in, the local environment. 6. A huge private sector, but mainly in curative care, with little involvement in preventive health. 7. Poor delivery of health services and, like the rest of the public sector, no accountability. 8. While all these problems exist, the fact that the government spends only 0.7 per cent of GDP on health does not help either. 9. In health sector more inequalities prevails in the share of the lower and upper quintiles in government expenditures in health sectors. So expenditure in Preventive Measures sub-sector is progressive. While the expenditures on Mother and Child, and on General Hospitals and Clinics are regressive at-least at provincial level.
10. Overall, the public sector spending on health sector is partially progressive in Pakistan. The emphasis of governments in the past, as reflected in the Five-Year plans, has been to increase the quantity of health-related services – numbers of doctors, Rural Health Centers, Basic Health Units, etc. Often the zeal to meet numerical targets has compromised the quality and type of facility provided. The end result has been unmanned and unsupervised health services. For example, Rural Health Centers and Basic Health Units, while available now in most of the rural areas of the country have merely become a source of adequate, efficient, and cheap health care. With fiscal constraints evident at all tiers of government, and with different levels of government having to be more discretionary in their use of resources, it is time now that the government focused on quality and performance, rather than on quantity. There is a growing need felt by many to democratize, devolve, and decentralize all avenues of civil society. The structure by which the delivery of health care is administered can also have important bearings on the quality of health delivery and, hence, on health outcomes. If reforms in government take place, and if local governments are given a greater say, in terms of finances and skills, in running the lives of their cohort population, accountability and control of the smallest health facilities could be brought under the supervision of district government. while facilities have been provided in most areas, the absence of medical staff allocated to those facilities has made them ineffective. With supervision, control, and accountability at the local level, the users of those facilities may, over time, develop the methods to ensure adequate delivery. In addition, managerial, administrative, and co-ordinating systems need to be strengthened to ensure the efficiency of the health delivery mechanism. Given the need to promote social development and health care, the government should continue to own its large asset base in the health sector. The transfer of essential and basic services like health from the public to the private sector may put such services out of the reach of a very large number of users, many of whom may have no choice but to use the
existing government facilities. The emphasis in the next few years should be on the better use of limited existing resources. While the privatization of existing health facilities is not recommended, this is not to say that the private sector is to be discouraged. On the contrary, the private sector plays an increasingly critical if not a dominant role in the delivery of health care, especially in urban areas, but also, increasingly, in rural areas as well. The government is not in a position to provide health for all without assistance from the private sector. The private sector should be encouraged to grow, but it should also be made aware of its social responsibilities. While the profit motive drives much of the health industry, some sort of taxation or cross-subsidization will have to be introduced into the health industry to support the efforts of the government in providing health care to those who cannot afford the higher private sector prices. The public-private partnership philosophy can be made very productive in the health sector.
http://www.aku.edu/CHS/pdf/HealthSituationandTrend-Pakistan,2001.pdf http://www.pakistanstudies-aips.org/English/about_economy.htm http://www.sdpi.org/whats_new/recent_publications/GAPA_Health.pdf http://www.sbp.org.pk/reports/quarterly/fy04/Special%20Section%201%20RyKh an%20Health%20Projec.pdf http://www.pmpch.org/objectives.html
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