RURAL SOCIOLOGY

HEALTH ISSUES IN PAKISTAN & GOVERNMENT S ROLE

Syed Nauman Tauqir Ali Raza Khurram Rana Uliya Suleman M.A IV

Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman Contents

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The issue of health ..................................................................................................................... 3 Cleanliness / Hygiene .............................................................................................................. 4 Water Pollution ....................................................................................................................... 5 Medical Conditions ................................................................................................................. 6 Child Health Issues .................................................................................................................. 7 Women Health ........................................................................................................................ 8 Health according to Islam ........................................................................................................ 9 Health Indicators and Targets .................................................................................................. 12 Total Expenditure on Health (Federal &Provincial) ................................................................ 12 Financing Health (2009 stats) ................................................................................................ 13 Health Investment by Government of Pakistan & Partners (2008 stats) ................................ 15 Health Delivery System (2008 stats) ...................................................................................... 16 Burden of Disease (2009 stats) .............................................................................................. 17 Infant Mortality Rate (2009-10 stats) .................................................................................... 18 Government of Pakistan s Expenditure on Health Affairs and Services (2008-09 stats) ......... 19 Statistics about Hospitals in Pakistan (2008 stats) ................................................................. 19 Statistics about Registered Doctors and Nurses in Pakistan (2008 stats) ............................... 20 Per Capita Water Availability (2009 stats) ............................................................................. 21 Pakistan s Water Scenario ..................................................................................................... 21 Wastewater produced annually by towns and cities (2007 stats) .......................................... 22 Estimated Cost from Water related Mortality and Morbidity ................................................ 24 Government s role ................................................................................................................... 25 Health Policy of the Government .......................................................................................... 26 Government s Health Programs in Pakistan .......................................................................... 28 Bibliography ............................................................................................................................. 31

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman

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PAKISTAN S HEALTH CHALLENGES AND GOVERNMENT S ROLE

The issue of health Health is an important sector in human life. In Pakistan, attempts have been made to improve the health conditions of the people through availability of trained personnel, adequate supply of medicines and establishment of health services. Yet the health care system as a whole is not encouraging. The main health problems are preventable communicable diseases, severe malnutrition and high incident of birth resulting of high proportion of infant and maternal mortality. There are also clear differentials in health conditions by rural and urban areas and socio-economic groups. Malaria, Tuberculosis and wide variety of childhood diseases such as diarrhea, measles and tetanus etc. still continue to pose potential threat to the health of millions of people in the country. Unsanitary condition, polluted water and illiteracy among rural mother, urban slum and high fertility, small budgetary allocation and inadequate administrative structure have been identified as the main hurdles in the progress of health conditions. Amongst the population of Pakistan, the burden of diseases can be classified under two broad categories: half due to communicable diseases, reproductive health and malnutrition while the other half due to non communicable diseases, injuries and mental health disorders. Polio and hepatitis B & C are endemic and Pakistan ranks 6th amongst the 22 highest TB burden countries in the world. In parts of Pakistan, malaria and dengue fever are prevalent and HIV is increasing among some segments of the population. At least one quarter of Pakistani adults are obese, have cardiovascular conditions and over 40% of men are smokers. Injuries and accidents account for more than 11% of the burden of diseases. Nutritional disorders are common and particularly effect women and children. Pakistan also needs to be prepared for emerging global diseases like swine flu and other viral infections. Pakistan has a high fertility rate with 4.2 million new births annually. This rapid population growth will further strain an already overstretched and underperforming health care services delivery system, including deliveries by skilled birth attendants. Efforts made over the years to improve health standards have been partially neutralized by the rapid growth of the population. In addition, gender bias and limited access to health services further compromise health of Pakistanis. Page 3 of 32

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Sub-optimal performance of the health sector in Pakistan is primarily because of low level of health spending. Total expenditure on health as percent of GDP is only about 2 percent of GDP, which is much lower than other countries with similar income levels. The government contributes about a third of this and the remaining 70 percent is paid out-ofpocket by citizens at the points of service delivery. A number of non-financial constraints have played an equally important role in the underperformance of health systems. Health workers are demotivated and distracted from their work by conflicting interests. Weak governance, imbalance of human resource, lack of equitable service delivery, absence of social safety nets, lack of effective implementation of regulations particularly in a large unregulated private sector are some of these factors having an adverse impact on the performance of the health sector. Pakistan faces numerous problems in the health section which are discussed herein.

Cleanliness / Hygiene About 80% of all major diseases such as diarrhea, cholera, typhoid, hepatitis are due to unsafe drinking water, inadequate sanitation and poor hygiene. Health and hygiene are causing major disruptions in the lives of people of Pakistan. Outside the houses, you will see the reckless disposal of wastage. Just outside the boundary wall of house, there will be the waste of that or other houses in the street. The streets are littered with garbage, which include papers, polythene bags, stale meals, dung, debris and other weird things. People habitually throw things in street after cleaning their houses. Commuters throw wrappers and other things from the vehicles while traveling. Picnic spots and parks have converted into a heap of dung. You will commonly see people urinating on the sidewalks. There are many roads and streets which are suffering from the disorder of sewerage system. Cleanliness has been declared as an element which comprises the half part of faith of Muslims. Ironically, more than 98% of Pakistanis are Muslims.

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Water Pollution Water is an essential element for our survival. Unfortunately, while Pakistan is blessed with adequate surface and groundwater resources, rapid population growth, urbanization and unsustainable water consumption practices have placed immense stress on the quality as well as the quantity of water resources in the country. Deterioration in water quality and contamination of lakes, rivers and groundwater aquifers has resulted in increased waterborne diseases and other health impacts. Per capita water availability in Pakistan has decreased from 5,000 cubic meters per annum in 1951 to 1,100. The principal source of drinking water for the majority of people in Pakistan is groundwater. About 80% of the Punjab has fresh groundwater, but in Sindh, less than 30% of groundwater is fresh. In NWFP, increasing abstraction has resulted in wells now reaching into saline layers, and much of Balochistan has saline groundwater. As per Government figures, the Punjab has the best rural water supply amongst the provinces. It is stated that only 7 % of the rural population depends on a dug well or a river, canal or stream. In Sindh, some 24% of the rural population depends on these sources. The rural water supply situation in NWFP and Balochistan is worse; about 46% and 72% respectively of the rural population depend on water from a dug well or from a river/canal/stream. Unchecked use of hazardous chemicals, vehicle emissions, and industrial activity has contributed to a number of environmental and health hazards, chief among them being water pollution. Much of the country suffers from a lack of potable water due to industrial waste and agricultural runoff that contaminates drinking water supplies. There is very little separation of municipal wastewater from industrial effluent in Pakistan. Both flow directly into open drains, which then flow into nearby natural water bodies. There is no regular monitoring programme to assess the water quality of the surface and groundwater bodies. There is no surface water quality standard or drinking water quality standard in Pakistan. It is estimated that 40 million residents depend on irrigation water for their domestic use, especially in areas where the groundwater is brackish. The associated health risks are grave, as bacteriological contamination of irrigation water often exceeds WHO limits even for irrigation. Page 5 of 32

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Major industrial contributors to water pollution in Pakistan are the petrochemicals, paper and pulp, food processing, tanneries, refineries, textile and sugar industries. Only a marginal number of industries conduct environmental assessments (about 5 % of national industries). The sugarcane based industry, the 2nd largest in the country, is a major cause of industrial water pollution. The problem of industrial water pollution has remained uncontrolled because there have been little or no incentives for industry to treat their effluents. The salinity level of groundwater is increasing. Industrial wastewater including toxic chemicals, organic matter and heavy metals is discharged directly into public sewers without prior treatment. There is reported leaching of wastes into groundwater, causing outbreaks of water-borne dis eases. At present, irrigation uses about 93% of the water currently utilized in Pakistan. The links between water quality and health risks are well established. An estimated 250,000 child deaths occur each year in Pakistan due to water-borne diseases. Apart from the human losses, these diseases are responsible for substantial economic losses. (Source for stats: Pakistan Council for Research in Water Resources)

Medical Conditions Human Resource in health care is not appropriately planned in Pakistan, with the result that there are more doctors than nurses, lack of trained midwives, urban concentration, brain drain from rural to urban areas and abroad, along with other issues related to curriculum, quality of graduates and their continuing supervision. The service structure for health workers is poorly defined. It favors tenure over competence, largely ignores technical capacities and does not allow incentives or rewards for performance. There is absence of doctors in government hospitals and clinics and medical staff only comes to mark their attendance and go away and are not available at the time of need or emergency. Furthermore, quacks are destroying the health of innocent people. More than 600,000 quacks are operating across the country. Quacks trap credulous people by making false claims and through media Page 6 of 32

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campaigns. These practitioners advertise through hoardings inscribed with misleading claims and through wall chalking in commercial and residential localities across the country. Many of these quacks are rapists and lure naïve patients towards them with the intention of raping them. Unhygienic conditions and use of unsterilized equipment by quacks sitting at different localities are spreading a number of diseases including cancer, hepatitis B and C, and AIDS. A number of quacks are doing business unchecked while the main cause for spread of these diseases is dental treatment. HIV/AIDS spreads through unscreened blood transfusion, reuse of used synergies and unsafe sexual behavior. The disease also spread through use of used razors and needles mainly amongst drug addicts. There is a dire need to create awareness among people, of the disease for their protection. Child Health Issues Child health in Pakistan is among the most important national issues that have been given much attention. Nutritional disorders are common and particularly effect women and children. According to statistics, 27 infant deaths occur per thousand, 19 child deaths per thousand and 11 percentage babies are born with low birth weight. The child mortality in Pakistan is a major cause of concern, with every 1 among 10 children dying before reaching the age of five and 1 among 30, just after they are born. Pneumonia and air pollution seem to be the factors affecting the health of the children. Some other reasons of why child birth issues arise are:        High fertility rates Lack of skilled birth attendance Insufficient availability of proper maternal and child care services Communicable diseases Low female literacy poverty Insufficient emergency obstetric and newborn care system Lack of clean water and hygiene milk

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman Women Health

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Ours is a male dominant society where only very few females enjoy full rights and have access to opportunities of even very basic human needs. This is even more true in the health sector, where unfortunately there is a great lack of female doctors combined with a large number of female 'quacks' in the country and the situation is at its worst in some rural areas where there is only one or two qualified female doctors. The female doctors are neither easily available nor easily affordable and women do not prefer to be examined by male doctors. There are a lot of government hospitals which provide free or low fee treatment to women but those are not preferred because of:     The casual and offhand behavior of doctors More than one male doctor examining the patient at one time The fear of crowds of medical students present at time of examination The fear that doctor may misuse this opportunity for some evil deed

Women in rural Pakistan have lesser access to health care than men, because of absence of female doctors. Factors like lack of awareness regarding women s health requirements, low literacy ratio, low social status and civil constrains on females are responsible for women s below standard health. Intra-household bias in food distribution leads to nutritional deficiencies among female children. Early marriages of girls, excessive childbearing, lack of control over their own bodies, and a high level of illiteracy adversely affect women's health. More than 40 percent of the total female population is anemic. The maternal mortality rate is high, as only 20 percent of women are assisted by a trained provider during delivery. In rural areas, women are unaware of contraceptives, thus sexually transmitted diseases and bad health in women are common. They are at a risk of contracting HIV-AIDS and other sexually transmitted diseases (STDs) because of male dominance in sex relations and lack of access to information. In these areas, women are like slaves subject to drudgery. They are there just to obey their fathers, brothers and husbands. They do not have the right to decide about themselves because women are considered as foolish creatures according to the dominant social and cultural norms. Likewise marriage is also a sort of trade between different families both in the rural and urban areas. They are highly vulnerable to violation of their rights to life. Many women lose their lives in the name of honor killings. Page 8 of 32

Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman

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There is a direct link between the health statuses of women and women s low societal standing in Pakistan. For instance, the maternal mortality rate in rural Balochistan is 800 maternal deaths to 100,000 live births. This ratio in the end adversely strikes at the health of her children as well as national economy. Not only can these but evident differences among health status of women and men are visible in Pakistani polity. The poor women s health is as much a social plight as much it is medically. Factors like lack of awareness regarding women s health requirements, low literacy ratio, low social status and civil constrains on females are responsible for women s below standard health in Pakistan. Men and women both are poorly educated about family planning consequently affecting the health of mother and child. Perhaps the greatest loss to the family and economy of a country as one need to comprehend that woman is the glory of all that is created. Health according to Islam From an Islamic perspective health is viewed as one of the greatest blessings that God has bestowed on mankind. It should be noted that the greatest blessing after belief is health, as narrated in the following Hadith:

The final messenger of God, Prophet Muhammad (pbuh) mounted the pulpit, then wept and said, "Ask Allah (swt) for forgiveness and health, for after being granted certainty, one is given nothing better than health." Related in Tirmidhi

Islam emphasizes on not taking health for granted. God has entrusted us with our bodies for a predestined period of time. He will hold us to account on how we looked after and utilized our bodies and good health. The preservation of this blessing can only be achieved through taking good care of one s health and taking every measure to maintain and enhance it. With this in mind every Muslim should make sure they undertake all necessary actions which are conducive to the preservation of good health. Healthy living is part and parcel of Islam, introduced with the inception of Islam more than 14 centuries ago. Furthermore, the Quran and the Sunnah outline the teachings that show every Muslim how to protect his health and live life in a state of purity. Numerous examples in Islam instruct its followers to live a healthy life by performing actions such as: Page 9 of 32

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Daily Prayer  Ablution / Ghusal  Taking good / healthy diet and nutrition  Fasting  Prohibition of intoxicants Islam places great emphasis on cleanliness, in both its physical and spiritual aspects. On the physical side, Islam requires the Muslim to clean his body, his clothes, his house, and the whole community, and he is rewarded by God for doing so. Prophet Muhammad (pbuh) said, for example: "Removing any harm from the road is charity (that will be rewarded by Allah)." [Bukhari] While people generally consider cleanliness a desirable attribute, Islam insists on it, making it an indispensible fundamental of the faith. A Muslim is required to be pure morally and spiritually as well as physically. Through the Qur'an and Sunnah Islam requires the sincere believer to sanitize and purify his entire way of life.

In the Qur'an Allah commends those who are accustomed to cleanliness: "Allah loves those who turn to Him constantly and He loves those who keep themselves pure and clean." [2: 22] In Islam the Arabic term for purity is Taharah. Books of Islamic jurisprudence often contain an entire chapter with Taharah as a heading. Allah orders the believer to be tidy in appearance: "Keep your clothes clean." [74:4] The Qur'an insists that the believer maintain a constant state of purity: "Believers! When you prepare for prayer wash your faces, and your hands (and arms) to the elbows; rub your heads (with water) and (wash) your feet up to the ankles. If you are ritually impure bathe your whole body." [5: 6] Ritual impurity refers to that resulting from menstrual release, menstruation and the first forty Page 10 of 32

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days after childbirth. Muslims also use water, not paper or anything else to after eliminating body wastes. Prophet Muhammad advised the Muslims to appear neat and tidy in private and in public. Once when returning home from battle he advised his army: "You are soon going to meet your brothers, so tidy your saddles and clothes. Be distinguished in the eyes of the people." [Abu Dawud] On another occasion he said: "Had I not been afraid of overburdening my community, I would have ordered them to brush their teeth for every prayer." [Bukhari]

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman Health Indicators and Targets

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Some graphs and statistics related to health in Pakistan shows the reality of health conditions: Total Expenditure on Health (Federal &Provincial) Year Development Non-development Total Health Expenditure % of GDP 0.58 0.57 0.51 0.57 0.57 0.55 as

2003-04 2004-05 2005-06 2006-07 2007-08 2008-09 ‡

8.5 (25.9%) 11.0 (28.9%) 16.0 (40.0%) 20.0 (40.0%) 27.0 (45.0%) 33.0(45.5%)

24.3 (74.0%) 27.0 (71.0%) 24.0 (60.0%) 30.0 (60.0%) 32.0 (53.3%) 41.1(54.5%)

32.8 38.0 40.0 50.0 60.0 74.0

‡

The health expenditures have increased to 74 billion rupees in recent years however it has not increased in terms of % of GDP, the WHO recommended % of GDP on health is atleast 2% The development component of health expenditure has grown significantly

Source: Economic Surveys of Pakistan

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman Financing Health (2009 stats) ‡ ‡ ‡ ‡

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The following table shows the exact layout of health expenditure in Pakistan The annual per capita health expenditure is about 19 USD out of which 6.5 USD are spent by the Government of Pakistan channels and the rest of 65% is out of pocket expense. In developed countries the total health expenses are much higher e.g. UK has more than 2000 USD Total Health Expenditure (THE). However the recommendations for developing countries to achieve Millennium Development Goals by 2015 are to spend between USD 30-40 on minimal essential health services.

Pak Indicator Year 2009 Total health expenditure (THE) as % of GDP 2.6

Afgh

India

Bangl

9.2

3.6

3.2

General government exp. on health as % of THE

33.6

32.4

25

31.8

Private expenditure on health as % of THE

64.5

67.6

75

68.2

General government expenditure on health as % of total government expenditure

7.5

6.2

3.4

7

Social Security expenditure on health as % of General government expenditure on health

0.3

0

4.9

0

Per capita THE (US$)

19.37

27

29

12

Per capita government expend. on health (US$)

6.50

9

7

4

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman
C s

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5% 65%

‡

‡

We can see from above pie chart that the proportion of out of pocket expenses is high considering the poverty levels in Pakistan and the presence of an unregulated private sector. This inevitably leads to increase in poverty because of catastrophic health expenses.

Source: National Health Accounts Survey 

&%$# "!    

£ ¨ § © ¨ §   ¡  ¤ ¦¥¤£ ¡   ¢ ¢ ¢ ¢
e
3% 28%

c e

Tax

s

s

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman

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Health Investment by Government of Pakistan & Partners (2008 stats)

*GoP: Government of Pakistan *MoH: Ministry of Health *DoH: Department of Health *MoPW: Ministry of Population Welfare ‡ ‡ ‡ ‡ The amount contributed by health partners is about 20%. This is low as compared to other countries in the region and is variable depending on political environment. Donor money is mostly channeled into development projects. In order to achieve Millennium Development Goals targets. not only the Government spending should increase but it should also be complimented by international community.

Source: Inventory of H & P Investment Pakistan, GoP & WHO

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman Health Delivery System (2008 stats)

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‡ ‡ ‡

Pakistan has about 134,000 registered doctors and, 65,000 registered nurses with one bed for about 1500 of population. There are about 5000 basic health units and rural health centers in the Government sector spread all over the country. The private sector has a larger presence in urban communities and exact figures are not available.

Source: Population Reference Bureau

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman Burden of Disease (2009 stats)

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‡ ‡ ‡

‡ ‡ ‡

Pakistan has a double burden of disease. However, it is heavily dominated by communicable diseases as shown in the graph. Diseases like diarrhea, pneumonia, TB and Malaria are further compounded by malnutrition (about 45% of children and 50% of women are effected) leading to more than 50% share in mortality. In non communicable diseases heart conditions, diabetes, hypertension, cancer and injuries are important diseases. 11% of deaths are contributed by heart diseases. Polio is still present in Pakistan and efforts are being made to eradicate polio.

Source: WHO

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman Infant Mortality Rate (2009-10 stats)

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The table below shows the number of deaths of infants under one year old in a given year per 1,000 live births in the same year; included is the total death rate, and deaths by sex, male and female. Infant mortality rate: total: 67.36 deaths/1,000 live births male: 70.65 deaths/1,000 live births female: 63.91 deaths/1,000 live births Year 2003 2004 2005 2006 2007 2008 2009 2010 Infant mortality rate 76.53 72.44 72.44 70.45 68.84 66.94 65.14 67.36 33 36 37 37 33 32 32 28 Rank -5.34 % 0.00 % -2.75 % -2.29 % -2.76 % -2.69 % 3.41 % Percent Change

Source: CIA World Factbook

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman

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Government of Pakistan s Expenditure on Health Affairs and Services (2008-09 stats) Under health Affairs and Services a total allocation of Rs 6484 million has been made in the budget 2009-10. This allocation is higher by 18% when compared with budget of 2008-09. Details are given in the following Table: Classification HEALTH SERVICES AFFAIRS Budget 2008 09 Million PKR AND 5490 Budget 2009 10 Million PKR 6484

Medical Products, Appliances 54 and Equipment Hospital's Services R & D Health Health Administration 4892 2 195

65

5708 2 241

Statistics about Hospitals in Pakistan (2008 stats) Total Health Facilities: Hospitals: Dispensaries: Basic Health Units: Rural Health Centers: MCH Centers: TB Centers: 13,937 965 4,916 4,872 595 1,138 371

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman First Aid Points: Beds in hospitals & dispensaries: Population per bed: Population to health facility ratio:

RURAL SOCIOLOGY 1,080 105,005 1,515 11,413

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Source: Federal Bureau of Statistics, Government of Pakistan

Statistics about Registered Doctors and Nurses in Pakistan (2008 stats) Doctors: Doctors registered as specialists: Dentists: Dental specialists: Nurses: Midwives: Lady Health Visitors: Lady Health Workers: Lady Health Supervisors: Population per doctor: Population per dentist: Population per nurse: 107,835 19,623 7446 433 43,646 2,788 3,864 95,000 3,385 1,475 21,362 3,644

Source: Federal Bureau of Statistics, Government of Pakistan Page 20 of 32

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Per Capita Water Availability (2009 stats) Year 1951 1961 1971 1981 1991 2000 2010 2025 Population 34 46 65 84 115 148 207 267 Per Capita Availability (m3) 5300 3950 2700 2100 1600 1200 850 659

Source: Draft State of Environment Report

Pakistan s Water Scenario Year Availability Requirement(including drinking water) Overall Shortfall 2004 104 MAF 115 MAF 11 MAF 2025 104 MAF 135 MAF 31 MAF

It is observed that the expanding imbalance between supply and demand has not only led to water shortages but also initiated an unhealthy competition amongst end users, which is ultimately causing environmental degradation in the form of persistent increase in water logging in certain areas, decline of groundwater levels in other areas, intrusion of saline water into fresh groundwater reservoirs, etc. Source: Ten Year Perspective Development Plan 2001-11, Planning Commission

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Wastewater produced annually by towns and cities (2007 stats) Domestic waste containing household effluent and human waste is either discharged directly to a sewer system, a natural drain or water body, a nearby field or an internal septic tank. It is estimated that only some 8% of urban wastewater is treated in municipal treatment plants. The treated wastewater generally flows into open drains, and there are no provisions for reuse of the treated wastewater for agriculture or other municipal uses. Table below shows ten large urban centers of the country, which produce more than 60% of the total urban wastewater including household, industrial and commercial wastewater.

City

Urban Population

Lahore

5,143,495

Total Wastewater Produced (million m3/y) 287

% of Total

% Treated

Receiving Water Body

12.5

0.01

Faisalabad

2,008,861

129

5.6

25.6

Gujranwala

1,132,509

71

3.1

-

Rawalpinidi

1,409,768

40

1.8

-

River Ravi, irrigation canals, vegetable farms River Ravi, River Chenab and vegetable farms SCARP drains, vegetable farms River Soan and vegetable farms

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman Sheikhupura Multan 870,110 1,197,384 15 66

RURAL SOCIOLOGY 0.7 2.9 -

Final Assignment SCARP drains River Chenab, irrigation canals and vegetable farms River Ravi, irrigation canals and vegetable farms Arabian Sea River Indus, irrigation canals and SCARP drains Kabul River -

Sialkot

713,552

19

0.8

-

Karachi Hyderabad

9,339,023 1,166,894

604 51

26.3 2.2

15.9 34.0

Peshawar Other Total Urban

982,816 19,475,588 43,440,000

52 967 2,301

2.3 41.8 100.0

36.2 0.7 7.7

Source: Master Plan for Urban Wastewater (Municipal and Industrial) Treatment Facilities in Pakistan. Final Report, Lahore: Engineering, Planning and Management Consultants.

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Estimated Cost from Water related Mortality and Morbidity

Source: Pakistan Strategic Country Environmental Assessment Report, May 2008

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Government s role Government of Pakistan has made commitments to the Millennium Development Goals (MDGs). Through its major health intervention programs, the Ministry of Health has pursued strategies aimed at: y Reducing: o The under-five mortality rate from an estimated 140 in 1990 to a target of 52 by 2015. o The infant mortality rate from an estimated 110 in 1990 to a target of 40 by 2015. o The maternal mortality ratio from an estimated 530 in 1990 to a target of 140 by 2015. y Increasing: o The proportion of 1 year-old children immunized against measles from an estimated 50% in 1990 to a target of 85% by 2015. o The proportion of births attended by skilled health personnel from an estimated 20% in 1990 to a target of > 90% by 2015. y Combating: o TB, Malaria, HIV/AIDS and other communicable diseases. The 2008 report of the MDG Gap Taskforce revealed that while there has been much progress during the last decade, the delivery on commitments has lagged behind schedule. Pakistan has: y Reduced the under-five mortality rate by 25 during the 1990s but has achieved no further reductions in the past decade; Maintained the same infant mortality rate of around 75 in the past decade; Slightly increased the proportion of 1 year-old children immunized against measles to 60%; Page 25 of 32

y y

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y y

Significantly reduced the maternal mortality ratio to 280; and Doubled the proportion of births attended by skilled health personnel to 40%.

However, these gains would still fall short of the targets identified for the remainder of the current timeframe. The government is cognizant that there are other determinants of health, such as illiteracy, unemployment, gender inequality, social exclusion, food insecurity, rapid urbanization, environmental degradation, natural disasters, lack of access to safe water and sanitation that aggravate Pakistanis health status. The ministry of health has the human resource capacity and is willing to assume a leadership role wherever deemed necessary in initiatives that remove these barriers for the betterment of health and eradication of diseases. The effectiveness of health initiatives will only be maximally achieved if the ministry of h ealth is able to reach out to and help coordinate the activities of other authorities responsible for education, sanitation, water supply and environment. The Government recognizes that Primary Health Care (PHC) is the only practical approach to improve health of our population. The Government needs to strengthen the health systems to respond better and quickly to the challenges of an evolving Pakistan, resulting in a healthy nation.

Health Policy of the Government Vision The vision of the National Health Policy is to improve the health and quality of life of all Pakistanis, particularly women and children, through access to essential health services. Goal The goal of the national health policy is to remove barriers to access to affordable, essential health services for every Pakistani.

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Policy Objectives To achieve the above stated goal of removal of barriers to essential health services, the Government of Pakistan adopts the following six Policy Objectives to reform and strengthen critical aspects of its health systems to enable it to: 1. Provide and Deliver a basic package of quality Essential Health Care Services. 2. Develop and manage competent and committed health care providers. 3. Generate reliable health information to manage and evaluate health services. 4. Adopt appropriate health technology to deliver quality services. 5. Finance the costs of providing basic health care to all Pakistanis. 6. Reform the Health Administration to make it accountable to the public. The Ministry of Health recognizes that provinces have varied needs and expectations regarding health and that each Department of Health is fully capable of identifying as well as delivering appropriate health care to their populations. It is in this spirit that the federal ministry will support and facilitate the provinces in implementation of their strategies by providing relevant financial and technical resources to ensure that essential health service package is accessible to all the citizens. The national health policy has been formulated with the primary objective of resonating with the expectations of Provinces. It is designed to contribute to advancing and strengthening the provincial health strategies. The National Health Policy of Pakistan of 2009 sought to improve the health of the nation. Despite global financial constraints, national economic down turn and inefficiencies of the health system, the policy will harness existing resources to reduce the burden of disease in Pakistan and overcome barriers to access to health care for the very poor. It will do so by defining and delivering a set of basic health services for all by optimizing available funds use, improving health manpower, gathering and using reliable health information to guide program effectiveness and design by strategic use of emerging technology. To achieve these objectives

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman

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the policy will be guided by the Poverty Reduction Strategy Paper and Pakistan s international commitments such as to the Millennium Development Goals.

Government s Health Programs in Pakistan Expanded Program on Immunization (EPI) The Expanded Program on Immunization (EPI) was launched in 1978. It aims at protecting children by immunizing them against Childhood Tuberculosis, Poliomyelitis, Diphtheria, Pertussis, Measles, Tetanus and also their mothers against Tetanus. The Program has significantly progressed during the period of time in terms of immunization coverage and disease reduction and has developed its own surveillance system, cold chain system, field supervisory mechanism, regular monitoring system, evaluation strategy and sufficient trained manpower at all levels throughout the country. The expenditure by Federal Ministry of health on this Program for 2008-2009 was a total cost of Rs. 11.484 billion. This ensures the commitment of the Federal Government for provision of vaccines, syringes, cold chain equipment, transport, printed material and launching of health education/motivation campaign. National Program for Family Planning & Primary Health Care (LHW Program) The Program aims to deliver basic health services at the doorsteps of the poor segments of the society through deployment of Lady Health Workers (LHWs) living in their own localities. The program is currently being implemented in all the districts of the country. The program has strength of 96,000 LHWs nationwide with concentration in rural areas and urban slums of the country. Each LHW covers 1000 population or 150 houses. These workers are providing services to their communities in the field of child health, nutrition, family planning and treatment of minor ailments. Population coverage of the program is about 70%. National Tuberculosis Control Program Tuberculosis (TB) is a major public health problem in Pakistan. The country ranks 6th globally among the 22 high disease burden countries, and contributes 43% of the disease burden towards the Eastern-Mediterranean region of WHO. Responding to the challenge, the Government of Pakistan allocated an amount of Rs. 1184 million for the period of 2005-2010. Besides, the Global Fund has approved an amount of US$56 million to fill the funding gap.

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman

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National Malaria Control Program The goal of the Program is to improve the health status of the population by effectively controlling malaria through implementation of the Roll Back Malaria strategies. The five year plan is a step towards achieving the WHO global RBM target of 50% reduction in the malaria burden by the end of this year 2010. Considerable progress has been made with regard to involvement of NGOs, awareness and operational research. The Directorate of Malaria Control was successful win a grant of over US$23 million in Round 7 of the Global Fund. National Maternal, Neonatal and Child Health (MNCH) Programme Pakistan s Maternal and Child Health indicators remain extremely poor every year as 25,000 to 30,000 women die from complications of pregnancy and child birth. Millions more suffer ill health and disability. One million children die before the age of 5 while 16,000 die in the first month after birth. Prior to 2005, Ministry of Health did not have a separate strategy on MNCH, as a result of which the maternal newborn and child health services were w eak, insufficient and fragmented. The Ministry of Health established a cell in the Ministry in February 2005. National Programme for Prevention and Control of Hepatitis Responding to the growing trends of hepatitis in general population, the programme (2005-10) was launched to decrease substantially the prevalence, morbidity and mortality. National AIDS Control Programme Pakistan is the second largest country in SouthAsia that stands only a few steps behind India and Nepalin terms of HIV epidemic. Until recently Pakistan was classified as a low prevalence high risk country but now Pakistan is in a concentrated phase of the epidemic with HIV prevalence of more than 5% among injecting drug users (IDUs) in at least eight major cities. According to the latest national HIV estimates there are approximately 97,400 cases of HIV/AIDS in Pakistan. The National AIDS Control Program and its provincial units are currently implementing a program throughout the country to halt the HIV epidemic. The principal components of the program include interventions for target groups, HIV prevention campaign for general public, prevention of HIV transmission through blood and blood products, and capacity building and Programme management. The programme aims to control HIV/AIDS cases by creating awareness and promoting blood safety through strengthening safe blood transfusion services. Current cost of the program is of Rs. 2.85 billion (2008-09). Page 29 of 32

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Major components of the programme include expansion of interventions for vulnerable population, prevention of transmission through blood transfusion, improved HIV prevention by the general public through behaviour change communication, targeted intervention for youth, labour, and uniformed personnel.

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman

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Bibliography
Health care in Pakistan: http://en.wikipedia.org/wiki/Health_care_in_Pakistan Water pollution: http://www.environment.gov.pk/PRO_PDF/PositionPaper/Water%20Pollution.pdf Women in Pakistan: http://www.marxist.com/women-pakistan-victims-of-desecration.htm Quacks spreading aids: http://www.dailytimes.com.pk/default.asp?page=story_30-52005_pg7_36 People falling prey to quacks: http://www.pakspectator.com/naive-people-falling-prey-toquacks/ Analysis of maternal mortality: http://www.ayubmed.edu.pk/JAMC/PAST/152/shamshad%20maternal%20mortality.htm Maternal mortality rates in Pakistan: http://www.chowrangi.com/maternal-mortality-ratesin-pakistan-a-human-rights-issue.html Cleanliness in Pakistan: http://www.chowrangi.com/cleanliness.html Child health in Pakistan: http://www.mapsofworld.com/pakistan/health-care/childhealth.html The determinants of child health in Pakistan: http://www.sdpi.org/whats_new/recent_publications/The-Determinants-of-Child-Healthin-Pakistan.pdf Cleanliness in Islam: http://www.islamtomorrow.com/islam/cleanliness.htm Health and well being in Islam: http://www.missionislam.com/health/index.htm Women health status in Pakistan: http://www.chowrangi.com/women-health-status-inpakistan.html 

 

    

  

 

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Syed Nauman Tauqir, Ali Raza, Khurram Rana, Uliya Suleman      

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Women s health problems in Pakistan: http://www.mejfm.com/journal/oct03/Women.pdf Ministry of health Pakistan: http://www.health.gov.pk/ Pakistan Council for Research in Water Resources: http://www.pcrwr.gov.pk/ Economic Surveys of Pakistan: http://www.finance.gov.pk/finance_economic_survey.aspx WHO National Health Accounts for Pakistan: http://www.who.int/nha/country/pak/en/ National Health Accounts Pakistan: http://www.statpak.gov.pk/depts/fbs/publications/national_health_account2005_06/Natio nal_Health_Accounts.pdf Population Reference Bureau Pakistan: http://www.prb.org/Countries/pakistan.aspx CIA World Factbook Pakistan: https://www.cia.gov/library/publications/the-worldfactbook/geos/pk.html Federal Bureau of Statistics Pakistan: http://www.statpak.gov.pk/depts/index.html WHO: http://www.who.int/countries/pak/en/ Draft State of Environment Report: http://www.environment.gov.pk/pubpdf/StateER2005/Title%20&%20TOC.pdf Ten Year Perspective Development Plan 2001-11, Planning Commission: http://unpan1.un.org/intradoc/groups/public/documents/APCITY/UNPAN018851.pdf Pakistan Strategic Country Environmental Assessment Report: http://www.boellpakistan.org/downloads/Strategic_country_assessment.pdf 

 

   

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