Health and Sanitation

According to WHO “Health is a state of complete physical, mental and social well-being and not
merely the absence of disease or infirmity”

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”

Health in Pakistan
Pakistan as a developing country is struggling in many domains due to which the health system has
suffered a lot.

Pakistan ranks 154th among 195 countries in terms of quality and accessibility of healthcare,
according to a Lancet study. As a developing country with a mere 2% of its GDP allocated for total
health expenditures, Pakistan struggles to maintain a proper healthcare system with regard to quality and
accessibility. According to the study Pakistan has seen improvement in healthcare access and quality
since 1990, with its HAQ index increasing from 26.8 in 1990 to 37.6 in 2016.

Pakistan’s numerous cases of communicable and vaccine-preventable diseases highlight its struggling
healthcare system. Viral hepatitis, dengue, tuberculosis, malaria, typhoid, HIV and cholera have long been
leading causes of death. They are the result of overpopulated cities, poor sanitation, unsafe drinking water
and inadequate socioeconomic conditions.

Pakistan has one of the lowest amounts of immunized children, with overall vaccination coverage of just
60%. The result is a high newborn mortality rate: 69.3 deaths per 1,000 live births. Moreover, while the
rest of the world is free from polio, experts still consider the disease as an endemic in Pakistan.
Documentations determined that there were nearly 150 polio cases in 2019.

Healthcare in Pakistan includes both private and public sectors. The private sector serves approximately
70% of the population. Private hospitals and healthcare institutions consistently outperform their public
counterparts, as measured by the overall quality of healthcare and patient satisfaction.

A common misconception is that healthcare services in the public sector are free of charge to Pakistani
citizens. This is not the case, as 78% of the population continues to pay for healthcare out of their own
pockets.

Healthcare in Pakistan has been a focal point after the country signed the U.N. Millennium Development
Goals (MDGs). Pakistan began to initiate healthcare programs, establishing both Basic Health Units as well
as Rural Health Units. Basic Health Units are assigned to NGOs, who manage the day-to-day operations,
administer medicine and overlook the facilities.

Healthcare in Pakistan has gradually improved over time. Currently, 92% of the rural population and 100%
of the urban population have access to health services. Such improvement has been a direct result of
Pakistan meeting the MDGs. Despite measures to increase the quality of healthcare facilities, most of the
population prefers to consult private doctors and practitioners.

Pakistan continues to commit to the MDGs in order to eradicate a multitude of preventable diseases. The
introduction of immunization programs, such as the Expanded Program on Immunization (EPI), has
increased vaccination coverage in Pakistan from 5% to 84%. EPI partnered with the Global Alliance for
Vaccines and Immunization (GAVI), a global health organization dedicated to increasing immunization in
low- and middle-income countries. With this partnership, countless people are working to eradicate
vaccine-preventable diseases, such as measles, polio and neonatal tetanus.
With the arrival of COVID-19, Pakistan’s healthcare system is under immense pressure and is struggling to
deal with the thousands of cases arriving each day. Frontline workers are taking the brunt of the virus. An
estimated 3% of the total cases in the country consist of healthcare workers. Medical professionals are
resorting to strikes and protests over the lack of protective gear necessary to safely treat patients.

In light of the unrest, Prime Minister Imran Khan announced new healthcare reforms to fix the faults of the
health sector. The reforms allocate $300 million to pay for additional ventilators and other medical
equipment. Additionally, major cities are setting up isolation centers to increase hospital capacity for
infected patients.

Health infrastructure
Primary Health Care[edit]
Primary Healthcare system is the very basic health system for providing accessible, good-quality,
responsive, equitable and integrated care. Primary healthcare in Pakistan mainly consists of basic
health units, dispensaries, Maternal & child health centers (MNCH) and some private clinics at
community level. In Sindh (Province in Pakistan), Primary healthcare activities are supported by
government itself but managed by external private & non-government organizations like People's
primary healthcare initiative (PPHI Sindh), Shifa foundation, HANDS etc.

Secondary Health Care[edit]

It mainly includes tehsil & district hospitals or some private hospitals. Tehsil & district hospitals
(THQs & DHQs) are run by the government, the treatment under government hospitals is free of
cost.

Tertiary Health Care[edit]

It include both private and government hospitals, well equipped to perform minor and major
surgeries. There are usually two or more in every city. Most of the Class “A” military hospitals come
in this category. Healthcare and stay comes free of charge in government hospitals. There is also a
24 hours emergency care that usually caters to more than 350 patients every day. [10]

Other health related services[edit]

The government of Pakistan has also started “Sehat Sahulat Program”, whose vision is to work
towards social welfare reforms, guaranteeing that the lower class within the country gets access to
basic medical care without financial risks.[11] Apart from that there are also maternal and child health
centres run by lady health workers that aim towards family planning and reproductive health.
Problems in Pakistan health system Major problems are :

• Inadequate funding
• Lack of health facilities in rural areas

• Unemployed doctors

• Acute shortage of doctors & trained medical personnel

• Brain drain' of medical graduates

• Increasing prices of medicines

• Circulation of fake medicines

Inadequate funding
As per the Economic Survey of Pakistan (2020-21), the country is spending 1.2% of the GDP on
healthcare [15] which is less than the healthcare expenditure recommended by WHO i.e. 5% of GDP.
Resulting in limited allocations for personnel, equipment and infrastructure in health sector.

Lack of health facilities in rural areas

Public healthcare institutions that address critical health issues are often only located in major towns
and cities. Due to the absence of these institutions and the cost associated with transportation,
impoverished people living in rural and remote areas tend to consult private doctors. [5] Studies have
shown that Pakistan's private sector healthcare system is outperforming the public sector healthcare
system in terms of service quality and patient satisfaction, with 70% of the population being served
by the private health sector.

Even before the COVID-19 pandemic, visiting a doctor in rural Pakistan was an expense few could afford.

Almost 70% of the Pakistani population lives in underserved rural areas, where healthcare services are
hindered by the lack of medical personnel, sparse facilities, and the high cost of treatments.

Most of health facilities and medical personnel e.g. ( 85% of practicing doctors ) are found in urban areas
– Because of Discrimination against rural inhabitants

Since dominant classes live in cities the best facilities are also provided there.

Things worsened in the wake of COVID-19, which disrupted supply chains and interrupted the delivery of
vital medicines.
Increasing prices
In such scenario where from food to petrol everywhere fire of inflation has engulfed the poor man

Those with money can afford the health facilities but the poor face many hurdles

People living in poverty ARE?

Households unable to meet health care expenses_ 30%

Acute shortage of doctors

Around 5000 doctors are coming every year in the field. (PMDC)

A sizeable number of women graduates are not practicing. As per PMDC’s 2018 report, 75% of
students in Pakistani medical universities are female but only 23% of registered doctors are
female. When both these statistics are analysed, one realises the alarming rate at which most
medical students in Pakistan end up not practising medicine.
For a country with a population of 225 million, Pakistan officially has 230000 doctors, 145000
nurses and 24000 dentists according to Government records which creates a shortage of 1.6
million nurses, 0.4 million doctors and 0.2 million dentists. For the ongoing COVID-19 crisis,
experts predict that Pakistan has a shortage of 1.4 million nurses and 0.2 million doctors which
could have a detrimental impact on the healthcare system and economy
The globally recommended ratio of doctors to nurses is 4:1, which is almost reverse in Pakistan
(1:3) (by WHO)
In governmental hospitals – each doctor examines more than 100 patients daily – international
standard are 25.

Even though nurses play a key role in any country's health care field, Pakistan has only 75,000
nurses to service a population of 200 million people, leaving a shortfall of around a million nurses
as per world health organisation estimates.

Brain drain of medical graduates

Brain Draining means the out flow of the human capital from home country to the foreign
country. There is increasing rate of brain draining from the last decades in Pakistan. Brain
Draining has many causes like unemployment, lack of Government  support, low facilities in
home country, life threat, desire for better urban life etc always lead the people toward migration
which is loss for home country if they will not return back or will not sent foreign remittances to
their home country.

We are also painfully aware that Hardly any country has suffered more from the brain drain than
Pakistan has. Nearly 3,500 (annual) graduates of Pakistan’s medical colleges are jobless and
plan to go abroad and never return to their home country. According to officials, estimates of
Pakistan’s Overseas Employment Corporation, about 36,000 professionals including doctors,
engineers, teachers, skilful labours in various fields has migrated from Pakistan to foreign
countries in the last 3 decades.

Reports estimate that there are roughly 175,000 doctors registered to serve the population. However, many
Pakistani doctors choose to practice abroad due to poor service structure, increased workload, lack of
funding and a rise in hostility by some. Moreover, many female doctors have stopped practicing due to
family and social compulsions. Taking into account all these factors,  the doctor to population ratio stands
at one doctor for every 1,764 persons. For adequate population coverage, Pakistan needs at least two
doctors for every 1,000 persons.

According to a survey of Gallup-Pakistan, more than two-thirds of Pakistan’s adult population

wants to go abroad for work and half of it has no desire to return.

Circulation of fake medicines

Some research indicates that about 40-50 per cent drugs available in Pakistan are counterfeit, a figure
quoted by a dated study by the Aga Khan University, Karachi, funded by WHO 
Fake medicines are available for cure of from Flu to cancer.

Around 95 per cent of pharmacies, commonly known as ‘medical stores’, in Pakistan do not have
qualified pharmacist to dispense medical prescriptions.

Only 5 per cent of more than 40,000 pharmacies in Pakistan have qualified pharmacists while around
15,000 qualified pharmacists are jobless and an overwhelming number of the medical stores are run by
unqualified managers.

A large amount of these false medicines are producing in Karachi, Lahore, Rawalpindi and Multan.

Research in Health Sector

There is lack of interest and orientation in the field of medical research. Research in
health sector can provide important information about disease trends, risk factors,
outcomes of treatment or public health interventions and health care costs.

Clinical trials provides information about efficacy and adverse effects of medical
interventions by controlling different factors that can affect the results of study. It also
play a vital role to record and assess experience in clinical practice in order to develop
guidelines for best practices and to ensure high-quality patient care.

The development of new therapies and remarkable improvement in health care and
public health is based on research in health sector. Research in health sector imposed
great challenges for the scholars. Although research is an important component at
postgraduate level but the quality teaching of students in writing medical research
paper is still a challenge.

Communicable Diseases
In Pakistan, many efforts have been made to improve the health system but still it
is not encouraging. The main health issues are due to lack of awareness, poor diet,
water pollution and hygiene problems leading to communicable and non-
communicable diseases. Poor medical facilities are also resulting in health
deterioration of underprivileged people of Pakistan. Due to the shortage of nurses
and doctors for rural areas, every year thousands of children die during birth or if
they survive, they suffer from one or two diseases. The increasing number of heart
patients mostly including children suffering from congenital heart defect is
alarming. The mortality rate of women is also high because they are treated by
midwives with no professional knowledge. 
Communicable diseases are found to be the prime cause of mortality in Pakistan.
Major reason for the rapid spread of the disease include over-crowded cities, low
health awareness, unsafe drinking water, inadequate sanitation and poor
socioeconomic condition. These diseases are

 Acute respiratory infection: It interfere with normal breathing and affect upper and
lower respiratory system. Symptoms include fever, runny nose, cough, difficult
breathing, sore throat, fatigue, pharyngitis, bronchitis and congestion in nasal
sinuses or lungs. Children with low immune system are more susceptible.
 Viral hepatitis: Viral hepatitis includes hepatitis A, B, C is a group of distinct disease
that affect the liver. Each type of hepatitis have different signs and symptoms.
 Symptoms are similar to those of the flu and include fever, fatigue, belly pain, dark
urine, joint pain, nausea, vomiting, jaundice and clay colored poop. The main cause
of hepatitis B and C is due to blood transfusions and equipment sharing such as
razors, toothbrushes and other household articles.
 Malaria: It is a life threatening disease caused by parasite. Majority of people living
in slums area suffering from disease. It is one of the top health issues in Pakistan.
 Disease is caused, when mosquitoes breed on unclean, stagnant and unsanitary
water conditions which is common in rural areas. Symptoms of disease are fever,
headache and chills. Malaria can also cause death, if left untreated. Use of nets and
mosquito repellents is common.
 Tuberculosis: Tuberculosis, is a serious infectious disease that affect on lungs.
Pakistan ranks in one of top 5 countries that highly susceptible to TB according to
WHO. Signs and symptoms are fever, fatigue, chest pain, sweat, chills, loss of
appetite, weight loss, coughing up with blood. Transmission of disease is by
sneezing and coughing. It can become deadly, if not treated on time.
 HIV/AIDS:  HIV/AIDS caused by human immunodeficiency virus. It is a sexually
transmitted disease and can be spread by contact with infected blood or from
mother to child during pregnancy. It is observed that there are around about
100,000 HIV positive cases in Pakistan.
 The major cause of this disease in Pakistan is the use of infected syringes. Sign and
symptoms of disease are fever, headache, joint pain, sore throat and swollen lymph
nodes. Government needs to take serious action to prevent the HIV AIDS because
disease is non curable but some medication slow down the progression of disease.

Non Communicable Diseases

About 41 million of peoples die from non-communicable diseases every year. Non-
communicable diseases includes cardiovascular problems, diabetes, cancer and
coronary heart disease. NCD also known as chronic diseases are of long duration and
are the combination of genetic, physiological, environmental factors.

These conditions are associated with older age group. These diseases are occur due to
rapid unplanned urbanization, globalization and population ageing. Unhealthy food
and lack of physical activity can cause raised blood pressure, increased blood glucose,
blood lipids and obesity.

We can resolve health issues by improving biomedical research, medical care,

improving strategic plans for public health and information technologies,
biotechnologies, by making good policies, planning and development of health services
and regulation of pure food and medicines.

Undernutrition
Nutritionally deprived children not only face difficulties in learning, but also are at prime risk of getting
infections, face difficulty in combating and recovering from diseases. According to National Nutrition
Survey 2018, around 40.2% children in Pakistan are stunted. [42] There are many reasons behind that
but the most important reason and one of the most contributing factors is breastfeeding (early
initiation of breastfeeding, exclusive breastfeeding & continuation of breastfeeding till 2 years of
age). Only 45.8% mothers started breastfeeding to their children on the first day of birth & only
48.4% mothers continued breastfeeding for exclusively 6 months (Exclusive breastfeeding).
Over-nutrition (Overweight/Obesity)
According to one study, "fat" is more dangerous for South Asians than for Caucasians because the
fat tends to cling to organs like the liver instead of the skin. [48]
According to National Nutrition Survey Pakistan (NNS 2018), The study estimated the proportion of
overweight children under five to be 9.5%, twice the target set by the World Health Assembly. [42]
Malnutrition in Adolescents (10-19 years)[edit]
Nutrition status among Adolescents (10-19 yeas of age) varies differently between boys & girls. In
2018, 21.1% boys and 11.8% girls are underweight, 10.2& boys & 11.4% girls are overweight &
7.7% boys and 5.5% girls are obese. More than half (56.6%) of adolescent girls in Pakistan are
anaemic, however only 0.9% have severe anaemia. [42]
Malnutrition in Women of Reproductive age (WRA)[edit]
In Pakistan, WRA aged 15–49 years bear a double burden of malnutrition. One in seven (14.4%) are
undernourished, a decline from 18% in 2011 to 14%, while overweight and obesity are increasing. In
NNS 2011 28% were reported to be overweight or obese, rising to 37.8% 2018. About 41.7% of
WRA are anaemic, about 79.7% WRA are vitamin D deficient, over a quarter of WRA (27.3%) are
deficient in vitamin A, 18.2% of WRA are iron deficient, About 26.5% of WRA are hypocalcaemic
while 0.4% are hypercalcaemic & 22.1% of WRA are zinc deficient. [42]
Micronutrient Deficiencies in children under 5 years of age [edit]
More than half (53.7%) of Pakistani children are anaemic and 5.7% are severely anaemic. It was
50.9% in 2001, 61.9% in 2011 and 53.7% in 2018. The prevalence of iron deficiency anaemia is
28.6%, zinc deficiency is 18.6%, vitamin A deficiency is 51.5%, vitamin D deficiency is 62.7%.

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. 

Recommendations
A healthy and functioning healthcare delivery system mandates mutually supportive and
symbiotic relationship and integrates primary, secondary and tertiary care. Such integration and
several strategies could be planned and implemented to improve healthcare delivery system of
Pakistan.
Following are the key recommendations to improve Healthcare sector of Pakistan:
1. It would be better to move away from curative biomedical model towards more extensive and holistic
approach. Other factors such as environment, social and cultural aspects need to be concurrently
addressed to improve the health of people.

2. It would be highly beneficial, if policy making is decentralized and delegated to districts, because they
can adopt better and realistic approach for the problems they encounter on daily basis.

3. More resources should be kept into capacity building of the administrators at district level to
understand contemporary health issues, because the root causes of problems are not addressed while
formulating policies, due to lack of knowledge about concerned place and population.

4. All stakeholders should be involved in planning, decision and implementation of programs at all levels
to ensure efficiency and sustainability of programs(19) .

5. Better monitoring and evaluation tools should be constructed to get valuable and unbiased feedback
to policy makers and implementers .
6. Other key measures can be taken to improve Healthcare sector of Pakistan; control population
growth, increase literacy rate, increase health budget, control corruption in public health projects,
regionalization of Healthcare services, and promote health education, proper check on quackery and
exchange of human resource and knowledge with developed countries.