5

Health

I ntroduction
EALTH
H
forms a n integral part o f human development and well-being. I t has widespread benefits that extend
ro nutrition, population, planning, labour, productivit: , environment, and many others. The World Health
Organisation (\VHO ) defines health as 'a state of complete physical, social, and mental well - being, and not
merely the absence of disease or infirmity' . 1
Food and nutrition are some o f the essential components o f health. The availability o f adequate food helps
sustain the nutritional level of a person. When the required nutritional intake is secured, a person is capable
of fighting off diseases and deficiencies. Hence, if a socieff wants growth and minimal inequality, access ro
nutrition and health care needs to be prioritised.
Low nutritional levels inevitably lead to several health issues such as stunting and wasting. These preventable
diseases have a negative i mpact on the economy The economic consequence o f such diseases has already
been fel t on Pakistan's economy; various types o f malnutrition are responsible for a 3 to 4 per cent loss to the
countrv's G D P 2
According ro the Global Nutrition Report, malnutrition and diet are bv far the biggest risk factors for the
global burden of disease. The economic consequences are measurable in losses of 1 1 per cent o f the GDP every
year in Africa and Asia. Relatively low-cost maternal and early- l i fe health and nutrition programmes offer very
high returns on investment. India had a higher rate o f child stunting than Pakistan but it has almost doubled
the rate o f stunting reduction i n the past ten years compared with the previous decade.
Changes in the indicators o f the health status of Pakistan over the last twenty-five years are presented in Table
5 . 1 . Life expectancv has risen, infant and maternal mortality rates have declined, and access to sanitation has
imprm·ed, while access ro drinking water has remained unchanged. The most worrisome aspect is an almost
four times increase in child malnutrition-the stunting rate has gone up from 1 2 to 45 i n this period.

An Overview
"fable 5 .2 presents a comparative analysis of the most recent health indicators of Pakistan and Sindh along with
rhose of Punjab. This analysis shows that the province performs poorh· as compared to Punjab and the national
average. Poor health indicators come as a surprise where the province leads in per capita income, urbanisation,
and adult literacy. A closer look at the factors responsible for the relative success of Punjab shows that better
management, improved governance, and higher public expenditures have collectivelv reinforced this outcome.
In 2 0 1 5- 1 6 , Punjab allocated 1 1 . 5 p er cent of its budget to health com p ared to 7.7 per cent by Sindh.3
Punjab's graph on public health spending is on the rise. Auwnomous boards ha\ e been formed at the district
level w superYise and operate various health facilities. The data shmvs rhar Punjab has done particularly well in
reducing child mortality, maternal mortalitv, and contraceptive prevalence rares. The Sustainable Development

90
 HEALTH 91

Table 5 . 1 : Health Status of Pakistan ( 1 990 and 20 1 5)

Health Indicator 1 990 201 5

Life Expecrancy 60. l 66.4
Child Mortaliry ( Under rhe age of 5 ) 1 38.6 81.1
Marernal Mortaliry (Dearhs per I 00,000 live births) 431 1 78
Improved warer source (% of population wirh access) 86 91
Improved sanirarion faciliries (% of popularion wirh access) 24 64
Tora! Expendirure on Healrh (% of GDP) 2.5 2.61
Child Malnurririon (Srunting i n Children Aged Under- 5 ) 1 2* 45
Physicians per 1 ,000 population 0.5 0.8
Contraceptive prevalence (any method) (% of women aged 1 5-49) 1 4. 5 3 5 .4*'
* Value obtained pertains to 1 99 5 because the relevant data for 1 990 is not available.
** Value obtained pertains to 20 1 3 because the relevant data for 20 1 5 is nor available.

Source: United Nations Development Programme, Human Development Report, New York, various years; World Bank
Open Dara <https:/ /dara.worldbank.org/>.

Table 5.2: Comparison of Health Indicators in Pakistan, Sindh, and Punjab (20 1 5)

Indicators Pakistan Sindh Punjab

I n fant Mortality (Per 1 ,000 Live Births) 65.8 82 75
Maternal Mortality (Per 1 ,000 Live Births) 178 2 1 4* 1 89*
Under-five Mortality (Per 1 ,000 Live Births) 89* 1 05 * 93*
Malaria Treatment Using ACT* (Malarial Drug) for children under age 5 - 1 5 .9 9.4
Hospira! Beds per 1 ,000 0.6 -
-
Nurses and midwives per 1 ,000 0.61 2.8
Hospitals per 1 ,000 -
1 .7 -
Life Expectancy 66.4 - 64**
Physicians per 1 ,000 population 0.8 0.59 0.63
Full Immunisation Coverage 53.0 35 56
Contraceptive Prevalence Rare (any method) (% of women ages 1 5-49) 3 5 .4 29 38.7
* Artemisinin-based Combination Therapy (ACT) .

** ' Health Department, "Punjab Health profile', 20 1 7, <http://health.punjab.gov.pk/l'unjab_Health_Profile>.

**Pakistan Demographic and Health Survey (20 1 2-1 3).

Source: National figures are taken from World Bank Open Data <https://data.worldbank.orgi> and Global Health Observatory (CHO)
data <http://www.who.int/gho/eni>; Government ofSindh and United Nations Development Programme, Sindh Multiple Indicator Cluster
Survey 2014, Karachi, 20 1 5; Government of Punjab and United Nations Development Programme, Punjab Multiple fndic.ttor Cluster
Survey 2014. Lahore, 20 1 5, Pakistan Medical and Dental Council.
92 T H E ECO N O M Y O f .\10 D E R N S I N D H

Goals ( S D G ) report of the U N D P pushes developing economies towards attaining the goal of a maternal
mortality of 70 per 1 00,000 births-the rate in Sindh is 2 1 4 for the same." Additionally, the Under Five
Mortality Rare ( U5MR) is 1 04 per 1 ,000 live births in Si ndh compared to that of the SDG goal of 25 per
1 ,000 births. ' In addition, Sindh's performance in respect to child mortalirY rate is also poor.
Another alarming aspect of Sindh's healthcare system is the disparitv, which exists between the rural and
urban areas. The maternal mortality rare of rural areas is twice that of urban areas.c' Disparity in i ncome levels,
access to quality education, i n frastructure, and healthcare faci lities, are the variables that help to explain this
phenomenon.
The province can proudly claim to have developed several first-rate health facilities, such as Aga Khan
University Hospital (AKUH), Jinnah Postgraduate Medical Centre (JPMC) , National I nstitute of Cardiovascular
Disease (NICVD) , Sindh Institute of Urology and Transplantation (SIUT), and Indus Hospira!, but preventive
services such as immunisation vaccination, and prenatal and antenatal care particularly in the rural areas lag
behind and require serious attention. Ir is the government that is the sole provider of preventive services.
In S indh, both the public and private sectors help provide curative healthcare services. Ir is the government
that is supposed to provide curative services in the rural areas bur the unqualified private practitioners dominate
the scene. Some of them are frauds and others are faith healers. Healthcare facilities in the public sector are
divided into three categories: primary, secondary, and tertiary. The primary sector comprises basic health units
( B H Us ) , rural healthcare centres ( RHCs), government rural dispensaries (GRDs) , maternal and child health
( M C H s) and tuberculosis centres. These centres of basic health provide services ranging from preventive to
curative measures. Secondary healthcare is provided by the raluka/rehsil headquarter hospitals (THQs) and
district headquarter hospitals ( D H Qs) . The tertiary care is provided mainly by reaching, private, charitable,
specialised, and m i litary hospitals.
In an attempt to promote services at the grassroot level, lady health workers ( LHWs) were introduced in
1 994. LHWs are trained to provide advice and health care to people living i n rural areas. They are responsible
for reproductive health, vaccinations, control of diarrhoea, and promotion of access to clean water. According
to the Planning and Development Department of Sindh, there are 1 4,243 general medical officers/ lady health
supervisors and 1 ,347 LHWs in Sindh.- The Sindh Health Profile 20 1 6 states that there are 790 B H Us and
1 24 R H Us. There are 3,075 people per doctor, 1 2 ,308 persons per nurse, and 1 , 5 2 7 persons per bed.8

Evol ution of the Healthcare Del ivery System

At the rime of Independence, Sindh's health sector faced a lack of resources i n terms of infrastructure as well as
healthcare staff. Table 5 . 3 shows the highly underdeveloped health system i n Sindh in 1 947. There was not a
single tertiary level facility worth its name in the whole province. Mostly it was dispensaries of various kinds that
provided most of the curative services and that too of a rudimentary nature. The situation worsened following
the influx of migrants i n to the province, which further stretched already limited resources. Government civil
hospitals were located at district headquarters, while there were few dispensaries in rural areas .
Since 1 970, there has been some expansion in the healrh infrastructure, bur it remains inadequate in relation
to the needs of the population. The ratio of hospital beds to population is still quite low and therefore access is
highly l i mited. Even i f access became easier, the quality of care is poor. Medical staff absenteeism i n the rural
centres is quite rampant. Some of rhe health centres are not even equipped with diagnostic tools and just one
or two maternity and child centres exist. \'Vhenever epidemics hit the rural areas, the situation could not be
controlled because of a lack of staff emplm·ed in the public health service.'l Clearly, there is still a wide gap
between the demand and supply of health services.
Health indicators for Sindh are relarivclv worse among rhe rural population of the province (Table 5 . 5 ) .
i\farernal and child health i ndicators are precarious. and i m m u n isation and \·accinarion coverage rares are
 H EA LI H 93

Table 'i.3: Dispensaries and Hospirals in Sindh ( 1 947)

Type of Dispensary or Hospital Sindh

Purely Municipal Dispensaries 21
Purely DLB Dispensaries 18
Municipal Hospital 3
Grant-In-Aid Dispensaries 67
Government Dispensaries 15
Government Hospitals 10
Grant-In-Aid Hospitals 2
Women Grant-In-Aid Hospitals 4
4
Post Wtir Development Schemes (1947-1952),
Women Private Hospitals
Source: Government of Sindh, Karachi . n.d., pp. 1 3- 1 4 .

Table 5 . 4 : Public Sector Hospital Facilities i n Sindh ( 1 970-20 1 5)

Hospitals Hospital Beds

Civil, Specialised, Civil, Specialised,
Teaching Teaching
Taluka, and Others Taluka, and Others
1 970 2 21 1 775 2084
1 975 6 30 2892 2464
1 980 6 51 4 1 95 56 1 5
1 98 5 6 65 3402 4079
1 990 6 74 4384 4833
1 995 7 78 5116 5059
2000 5 81 5330 54 1 4
2005 5 83 5474 6040
20 1 0 6 82 5799 5878
20 1 5 7 99 60 1 7 6499
Source: hgures for 1 970-2005 were taken from Bureau of Statistics, Sindh Dez•elopmmt Statistics, Karachi . Planning and Development
department, Government of Sindh, various years; Bureau of Statistics, Health Profile, Karachi, Planning and Development Department,
Government of Sindh, various years.

Table 5 . 5 : Sindh Urban and Rural Health I ndicators (2004 and 20 1 4)

2004 20 1 4
Indicators
- -
Urban Rural Urban Rural
Maternal mortality 240 410
I n fant monaliry 50 80 57 1 06

Multiple Cluster Indicator Sumey 201 4,

Child monaliry (Under 5) 68 1 17 69 1 39
Source: Government of Sindh and United Nations International Children's Emergency fund,
Karachi, 20 1 5.
94 I H F l · C O >J O '\ ! Y O F '\!O D E R � S l :\ l l H

unsatisfactory. The contraceptive pres·alence rate i s low and un met demand is rising with t h e passage of time.
Only 29 per cent of the couples of childbearing ages in Sindh at present use contraception.

E1ble 5 . 6 : Usage of Health Fac i l i ties ( I 980)

Private Government
Rural S i ndh 53.9 38.8
LJrban S i ndh 5 1 .6 43.5

Pim
�nur(C: \ 1 . B . :\hbasi. Socio Economic Chzr11t"tnDtit-.'- rf\\--o nztn in Sind hsueJ ;{fJ;'ain,y \Lnw'n�- Stt1tus, Karac h i . Economic Srudic.-. Centre.
�ind Rc�ion.d Organisatio n . 1 9 8 0 .

'fable 5 . (i shows that as far as back 1 980, private clinics in both urban and rural areas filled the void that had
been created by poor health facili ties provided by the government. The trend has picked up i n the last few
decades because of deterioration in government health and service delivery. People previously unable to afford
fees charged by private providers, particularly in rural areas, can now go to charitable dispensaries, clinics, and
hospitals.
Free eye clinics by Layton Rahmatullah Blindness Trust (LRBT) and free dialysis and transplantation by
S I L'T arc some of the shining examples of excellent charitable health service providers.
Ses·eral attempts to reform the health sector has·e been made, some with the assistance of donors such as the
\'Co rid Bank. For example, during 1 993-94, the government of Pakistan launched a social action programme
(S:\.P) with the funding from the \X'orld Bank, rhe objective of which was to improve deliverv of social services
to citi1ens and provide easy access to facilities. I n the health sector, efforts were focused towards the provision
of proper nutrition, better maternal and child care, effective family-planning programmes, and proper control
of comm unicable and non-communicable diseases.
H ms·ever, a flawed system of governance i n h i b i ted an effective exerntion of the p rojects that SAP had
ambi tiouslv set. Staff absenteeism was widespread because there was no proper mechanism for monitoring the
goals set bs· the social action programmed and no action was taken against them. The reporting was inaccurate
and rimck remedial action to solve the problems was not taken. The critical part of female paramedical staff
was nor filled. The i n itiatives such as health committees, cost recoven·. and health programmes were actually nor
i mplemented. Releases of funds were sporadic and much below what was requi red to meet the programmatic
goals. Consequently, due to poor governance and management, the goals set by the social action programme
could not be attained.
One of the positive aspects of SAP was that it introduced and promoted the concept of public - private
partnership in healthcare delivery. Other components where progress was made were family planning services
provision through health outlets and training of women medical officers (WM Os) and paramedics. Overall,
Sindh's performance under SAP was far below the satisfactory level.
Punjab, on the other hand, was applauded for i ts will and determination to excel in the field of health. A tight
monitoring s:·srem and merit - based recruitment made Punj ab's performance under the programme impressive.

Wome n , C h i ldren and N utrition

T h e role of women i n health care, spacing of children, nutrition, a n d cleanliness is critical. Education and
empowerment provide women with the confidence and knowledge to better rake care of their children, such as
in di agnosing a child's disease at an early stage and monitoring the nutr itional intake of their families.
 ! ! FA I T H 95

A lack of awareness among women aggravaces chc hcalch si macion in Sindh. According w a survev, few
women receive prenatal and antenatal care. 10 However, prcnacal and antenatal care are crucial during pregnancy,
which help improve the health of both the mother and her child. Research suggests that rhe tetanus toxoid
vaccination had slightly increased amongst married women in both rural and urban areas in recent years. 1 1 This
finding is important as the lack of tetanus roxoid is understood to contribute to the maternal mortality rate. 1 '
The delivery of preventive healthcare, particularly immunisation and vaccination of chi ldren to protect them
from diseases and malnutrition, is not up to mark. Prenatal and antenatal care should be a priority along with
the provision of maternity healthcare centres in rural areas. In Sindh, 50 per cent of the totJ! health budget is
allocated to Karachi while the remaining districts share the remaining 50 per cent. Ll 1erriary health and medical
institutions receive a disproportionate share of the budget allocation.

C h i l d M a l n utrition
Child malnutrition, which contributes towards stunted mental as well as physical growth, is one of the most
serious issues in Pakistan.
According to the National Economic Council (N EC) , one in three Pakistanis is deprived of nutritious
food . 1 ·1 Adequate provision of nutrition requires food security and equitable distribution and access. I n recent
years, the decline in the agricultural sector, has resulted in food shortages in some areas . 1 ° Climate change has
also increased fluctuations in the seasonal cycle, affecting food production, and has also increased the spread of
diseases. In 20 I 0, flooding in Sindh caused huge devastation and dislocation, resulting in accelerated migration
from flood affected areas to urban centres. Around 2 . 6 million acres of crop were damaged. 1 '' The people who
migrated had to switch from producing crops to seeking j obs or self-employment opportunities, exacerbating
the low food production problem.

Table 5 .7: N utritional Status of the Children in Sindh (%)-20 1 4

Indicator I Percentage
Stunting ( Moderate and Severe) 48
Underweight (Severe) 17
Wasting ( M oderate) 15
Overweight l

Source: Covernmcnr of Sindh and Uni ted Nations lnternarionJI Children's Emergency Fund, M11lriple Cluster lndi(llfor Suruev 2014,
Karachi, 20 1 5 .

Sindh's nutritional crisis has hampered the growth of children. As shown i n Table 5 . 7 almost quarter of
the children (48 per cent) are too short for their age, i . e. severely stunted. Stunting occurs as a resul t of
malnourishment or contact with infections at birth. Poor environmental conditions also hinder a child's ability
to grow. Other problems such as wasting ( 1 5 per cent) and being underweight ( 1 7 per cent) have also surfaced
due to nutritional imbalance. Wasting, when the child is underweight for their height, reduces their immunity,
putting them at the risk of death. Cnderweight is defined as being of a lower weight compared to an average
child of the same age. This increases the risk of mortality amongst children . 1 -
The poorest households are hit the hardest-64 per cent o f children belonging t o the lowest income quintiles
are stunted as compared to 24 per cent for the highest quintile.
96 T H E ECONOMY O F .\ ! O D E R:--.: S l !'.' D H

Karachi division, with the highest literacy rate and plentiful economic opportunities, has the lowest prevalence
of stunted children (3 1 .2), while on the other extreme, Kashmore has the highest rate (66.2) . 1 8 There are more
stunted children in rural areas than in urban areas. The prevalence of stunted children is lower in rich households
(22.6) as well as in households where the mother is educated ( 1 5 .7) . 1 "
School feeding programmes have been found to enhance nutritional levels and school attendance but
attempts in the past such as the Tawana Pakistan Programme have failed to yield positive results. An integrated
approach towards nutrition and food along with proper monitoring and supervision should be able to overcome
difficulties faced in the provision of n utritious food to school-going children.

M aternal Health and Fam i ly P l a n n i n g

One o f the main indicators o f the poor health status of women i n Sindh province i s the high maternal mortality
rate, which is 2 1 4 per 1 00,000 births compared to the national average of 1 78 (Table 5 . 2 ) . This vividly
demonstrates the poor socio-economic conditions which women are accustomed to in the province. In rural
areas, Girls are married off quite young in the country at large and especially in rural areas, which leads to
longer reproductive cycles in some cases and high maternal deaths in others.
Longer reproductive cycles have led to a total fertility rate (TfR) of 4 in Sindh.20 This is propelled by a
low contraceptive prevalence rate of 2 9 . Family planning program mes have faced major backlash due to the
conservative mindsets of the people. Women do not use contraceptives either by rheir own choice or by that of
their husbands. Less than one-third of currently married women acmallv use modern methods of contraception.
Utilisation of protection strongly correlates with the number of living children, woman's educational level, and
wealth status. Contraceptive prevalence was the highest in the divisions of Karachi and H;·derabad, and lowest
in the divisions of Larkana, Sukkur, and Mirpurkhas.
The key to family planning lies in empowering women through education and an improvement in their
economic status. An increase in knowledge allows them to better understand the social and economic problems
they face. They can be more confident in communicating with health professionals and will be willing to take
decisions related to their personal health. This will eventually lead to an increase in the utilisation of reproductive
health services.
To achieve the SDG of a maternal mortality ratio of 70 per 1 00,000 live births, the provision of antenatal
care is essential. Antenatal care entails informing women about the risks associated with pregnancy, particulars
of labour and delivery, and the importance of breast-feeding. Furthermore, guidance on birth spacing can
increase the chances of an infant's survival . Ir is an instrumental step in improving maternal health since it boosts
the nutritional intake of mothers, such as that of tetanus toxoid, which helps in controlling maternal deaths.
As many as three-fourths of women in Sindh received anten�nal care in 20 1 4, mostly provided by a medical
doctor in the ratio of 40:60 in public and private centres. 21 T\vo-thirds of deliveries are undertaken by a skilled

place at home, with an enhanced risk of fatalitv for both .

attendant, i.e., a medical doctor, nurse, midwife, or a lady health visitor. Less than a third of deliveries take

D i sease Prevention
Among common diseases, malaria has been a source of much distress recentlv due to outbreaks of dengue
fever. The detection of tuberculosis (TB) cases amount to 5- per cent on an average.2-' However, Si ndh has an
above national average figure of 87 per cent for treatment success rate. 2' Hepatitis B and C incidences in the
general population of Sindh was repo rted to be 2 . 5 per cent and 5 per cent respectively in the recent Multiple
Indicator Cluster Survey. 2 1
 H EALTH 97

According to the Sindh Aids Control Programme (SACP) of 2 0 1 4 , there were 994 new cases of H IV/Aids
in Sindh with 9 1 per cent of the patients being men. 25 Children had been infected either because of mother­
to-child transmission or because of thalassemia.26 More than one half of the reported H IV cases in Pakistan
were from Sindh of which 8 1 per cent were from Karachi. Injectable drug users (IOU) , and male and female
sex workers are most vulnerable to HIV. Jail inmates and street children are also at a high risk of contracting
this disease.27 Mental health issues have also been growing in Sindh. They account for 1 2 per cent of the total
foregone Disability-Adjusted Life Year (DALY) , a majority of which is due to clinical depression. The actual
rates are much higher, due to increasing inflation and violence over the years. This area of health has not been
explored in depth.28

I ntra-Regional Disparity
Stark disparity in health exists even between districts for a variety of reasons such as differences in government
attention, geographical location, budget allocation, role of the private sector, and development schemes. It may
be useful to examine the condition of the most backward district of the province, Tharparkar, which is also the
most health-stressed district. A number of factors such as unreliable livelihood, backwardness, geographical
location in arid zones, and inadequate health coverage have placed Pakistan at the list of medium development
countries-with the likes of Botswana, El Salvador, Iraq, Kiribati Nicaragua, and Zambia-in the 20 1 6 Human
Development Index (HDI). Over the past few years, children of Thar have been dying at an alarming rate.
Challenging living conditions comprising poor sanitation, inadequate supply of food, sparse health service, lack
of awareness of diseases, and an unhealthy lifestyle have contributed to the grim situation of Thar.

Table 5 . 8 : Comparison of Health Indicators in Tharparkar and Sindh (Percentage)-20 1 4

Indicators Tharparkar Sindh

Low-birth weight infants 1 0.3 7.8
Underweight (Severe) 68.8 17
Stunted (Severe) 63 24
Wasted (Moderate) 3 2 .9 15
Children who have ever been breastfed 93.9 95.6

Children who received minimum dietary diversity 1 .2 1 0.8

Neonatal Tetanus Protection (Percentage of women who
34.2 47.4
received at least 2 doses during last pregnancy)
Use of Improved drinking water 5 3.7 90.5
Use of Improved sanitation 1 8.9 64.6
Total Fertility 5.7 4.0
Antenatal care from any skilled provider at least once 30.6 79.7

Delivered i n Health Facility 2 0. 7

Source: Government of Sindh a n d United Nations Development Programme, Sindh Multiple Indicator Cluster Survey 2014, Karachi, 201 5.
65.3

A comparative analysis of health indicators of Tharparkar with that of Sindh raises severe concerns. Food
insecurity is of major concern and has resulted in malnutrition among children and put most of them at the
98 T H E ECO N O M Y OF M OD ERN SJ;-..; D H

verge of death. Thar's statistics for stunting, wasting, and being underweight are higher than Sindh's average.
Minimum dietary diversity is also the lowest in Thar. High maternal and infant deaths can also be attributed
to a lack of neonatal tetanus protection, at an appalling rate of 34.2, combined with low rates of antenatal care
from a skilled provider (30.6) and less deliveries raking place at a health centre ( 1 8.9). Since more children are
dying, this has led women to choose to have more children, which is evident from a high fertility rate of 5 . 7 .
Most o f the health problems ofTharparkar can b e attributed to i t s climactic condition of frequent droughts,
absence of alternative livelihood earning arrangements, lack of access to drinking water, etc. The climatic
situation ofThar remains unchanged over the years and it has taken a heavy toll on the lives of the people. The
climatic conditions have amplified the vulnerability of the poor and the weak. After the drought, women have
been reported to have stopped or reduced breastfeeding, which is a circumstance that is strongly correlated with
malnurririon. 29 Drought-struck areas have severe health problems like diarrhoea (87) , fever and malaria (82),
cough and respiratory tract infections (79), and, skin diseases (4 1 ) . io
Although 1 1 3 health facilities are available for the people ofThar, the services and facilities are inadequate as
only one district headquarter hospital has a capacity of fifty beds and three tehsil/taluka headquarter hospitals
have a capacirv of 80 beds . 1 1 This leads to overcrowding and long waiting rimes even in emergency cases. Sixry­
six per cent of the locals reported that the nearest facility, BHU, or dispensary, is at a distance of more than 5
km. On lv 32 per cent of the villagers agreed that rhe nearest facility was not functional.52
The cost of reaching the nearest health facility has a price range of PKR 1 ,000 to P KR 4 ,000 attached to
it, making access to healthcare virtually unaffordable. The average travel time to the closest health facility is of
about 2 to 4 hours. Brackish water from the wells is rhe main source of water and sanitary toilers arc almost
non-existenr.·n
Nevertheless, there have been initiatives attempting to address the crisis ofTharparkar. After the alarming
rates of malnutrition in Thar, the WHO, WFP, and UNICEF took immediate steps. Eighty children were
admitted at the nutrition stabilisation centre at D H Q Mithi. As many as seventy-one children were cured.5 '
However, the government needs to initiate development schemes to elevate the conditions of Thar. The
worst-stricken areas need to be provided with food supplements to mitigate malnutrition amongst children.
In order to maintain a hygienic standard of living, drinking water and sanitation need ro be improved. The
gm·ernment also needs to undertake water conservation projects and reinstall water facilities. Mobile health
reams should visit inaccessible areas. Lastly, awareness programmes on health and hygiene should be conducted
so rhar people can respond almost immediately to rhe symptoms of pre\·alent diseases.

Healthcare P roviders

PUBLIC SECTOR
The usage of rhe public-sector health facilities in Sindh is only 22 per cent, compared to 29 per cent at the
national kvcl. In rural and urban areas, private services are sought after for treatments and check-ups. Although
some healthcare centres in the rural areas are designed propcrlv, thev are under-utilised due to poor maintenance,
staff shortage, and mediocre management of equipment and facilities. Since the primary healthcare system
is not proper!\· functional, tertiary and teaching hospitals are utilised beyond their maximum capacity. The
LHW programme is a commendable initiative on the preventive side but its coverage extends to 20-43 per
cent. This programme needs to be expanded and reformed with better supervision, training, and resources to
i ncrease access ibilirv.
The number of teaching hospitals in the province has risen from m·o ro seven (Table 5.9) with almost three
times the increase in hospital beds. H owe\·er, meeting the demand still remains a major challenge. As low­
income famil ies invariablv use these hospirals, the rationing rakes place through administrarive discrerion or
 H EALTH 99

rent seeking. I nstances of poor patients denied immediate help at these hospitals have become commonplace
due to this demand-supply gap. Poor governance and weak management have been major stumbling blocks.
Several experiments, such as the introduction of autonomous boards of governors, were done but with little
success. Political i nterference in the human resource management of these hospitals has been a bane as most
specialists serving therein are politically well-connected. They do not wish to abandon thei r lucrative private
practices in large urban centres and move to places such as Larkana, Khairpur, and Nawabshah, where there is
a dearth of qualified specialists. The imbalance in the quality of medical personnel acts a 'pull' factor for people
from the i nterior districts of Sindh rushing to Karachi's Civil or Jinnah hospitals.35
The number of non-teaching hospitals such as rhose at the district headquarter or taluka combined have
multiplied almost five-fold, and their capacity is almost equal to that of the teaching hospitals. Upgradation
of facilities at these hospitals with diagnostic equipment, appropriate medical and paramedical staff, and
incentives could relieve much pressure on the teaching hospitals. Hospital beds have expanded more than two
times since 1 970; however, the population has grown more than three times. A backlog is accumulating as the
capacity i n these hospitals has failed to keep pace with population growth. The shortages therefore crowd out
the poorest among the poor who deserve public sector facilities the most. This inequitable access to basic service
such as health is one of the main contributory factors to the rural-urban disparities. An increasing number of
philanthropic organisations and individuals, who are donating funds, equipment, and volunteers to upgrade
public sector hospitals wards and theatres selectively, is making some difference, but this momentum has to
be sustained over time. Civil Hospital, Karachi , has two-thirds of its funds emanating from philanthropic and
charity organisations and individuals and only one- third from the provincial budget.
Some teaching hospitals do nor have proper equipment or machinery for the patients. This leads to less
patients and has an adverse impact on medical education .Y'

Table 5.9: Public Sector Health facilities in Sindh ( 1 970-20 1 5)

I
I Maternal
I Tuber-
I
Rural Health Basic Health and Child Teaching
Dispensaries culosis
Centres Units Health Hospitals
Clinics
Centres

- -
Number Beds Number Beds Number Number Beds Number Number Beds

49 -

-
1 970 44 19 82 9 2 1 ,775
- -
- -
1 97 5 47 60 27 1 08 13 2 2,205
-
-
1 980 85 60 52 640 14 6 4, 1 95
-
-
1 98 5 1 00 14 60 700 13 33 6 3,402
1 990 94 12 67 814 1 26 372 804 6 4,384
-
1 995 111 12 83 1 ,2 5 2 1 58 615 1 ,286 - 6 4,658
2000 22 1 4 92 1 ,364 1 69 701 I ,450 36 5 5 ,330
2005 340 G ') ') 1 , 464 1 74 7 53 1 ,550 40 5 5 ,474

20 1 0 420 6 1 06 1 ,5 8 2 1 86 772 1 ,586 40 6 5 ,799

20 1 5 865 6 1 29 1 ,629 1 87 798 1 ,5 9 8 94 7 6,0 1 7

D eve l op m ent Department, va r i o u ' ;.·c.u<.,; Bu n:.u1 of Srati,tio. He,;/t/1 Profile, Karachi, Planning and Development Department, Govcrnrncrn
Sources: The figures from 1 970-2005 h a ve been taken from Bureau o f Statistics, Dez•elopment Statistics ofSintlh, Karachi, Planning and

of Sindh, various year.'..

1 00 T H E ECO N O M Y OF M O D ER!': S ! '.',' D l-J

An analysis of the current public health centres such as dispensaries, RH Cs, and B H Us has been presented in
Table 5.9. From a glance at the data, it would appear that there has been a phenomenal increase i n the number
of facilities over the last thirty-five years. From only nineteen rural health centres with eighty-two beds i n 1 970,
there has been a tremendous rise to 1 29 RH Cs with 1 ,629 beds supplemented by 798 B H Us with 1 , 598 beds.

Table 5. 1 0 : Relevant Ratios of Availability of Health Services to Patients in Sindh (20 1 1 - 1 6)

Year Population per Doctor Population per Nurse Population per Bed
20 1 1 3 ,0 1 7 1 1 .4 1 3 1 ,406
20 1 2 2.986 1 ] , 584 1 ,436

20 1 5 2,997 1 1 ,739 1 .476

20 1 4 3 ,0 1 4 1 1 ,966 1 ,488

20 1 5 3,075 1 2, 308 1 ,527

20 1 6 3, 1 59 1 2,44 1 1 ,4 5 5
Source: Rurcau o f Srarisrics, Health Profile o{S111dh. f.:arachi, l'Lrnning a n d Dewlopmcnr I lcparrmcnr. various wars.

Table 5 . 1 0 shows that the ratio of availability of health services to population have remained stagnant without
any substantial improvement despite expansion in health facilities in the province.
However, this quantitative expansion docs not depict an accurate picture as far as access, responsiveness, and
quality of care is concerned. Unfilled vacancies of medical doctors, absenteeism of medical staff. poor patient
care, management, shortage of drugs, and sparse diagnostic equipment make it difficult for the sick to seek
relief at these centres.
A survey carried out in the context of PSLM (Table 5 . 1 1 ) i ndicates that the four main reasons for not opting
for public sector health facilities are inaccessibility to a government facility. absence of government facilities,
insufficient medicines, and i nhospitable behaviour of the staff

Table 5 . 1 1 : Reasons for Not Opting for Public Health Facilities in Punjab and Sindh (%) (20 1 3- 1 4)

Reasons Punjab Sindh

Too far awav 30 25
No Government Facility 18 9
Not enough medicines 15 12
Staff not courteous
Source: Pakistan Rureau o f Statistics, Pakistd11 Son,1/ ,;11d L 1 1 ·mg Sr,znd.mls ,\fe,u11rm1ent Sun'<') i/'SLJ!) 2013-14, Islamabad. Statistics
8 14

Division. ( ;ovcrnmcnt of Pakistan) p. 93.

The recent i nitiative of the Sindh government to oursource these facilities to private or non-governmental
organisations under Public- Private Partnership is a step in the right direction. According to the health facilities
Sindh provincial report, only 5 5 per cent of infrastructure components were available and functional at BHUs . i�
Labour rooms and LHV residences were anilablc in 3- per cent and 59 per cent of B H Us respectively.
 H EALTH 101

There has been a proliferation of private medical colleges i n Sindh i n the recent years. Serious questions have
been raised about the quality and accreditation of some of the medical colleges. Standards are lax, violation and
infringements of standards are rampant, and enforcement is weak. The Pakistan Medical and Dental Council
(PMDC) was revamped recently but it is too early to assess the results.
The new medical colleges established in Mirpurkhas and Sukkur, for example, do not have the minimum
number of qualified teachers, or the laboratories or equipment needed for a standard medical college. There
is already an excess of doctors being produced every year by the existing u niversities and colleges, but their
effective participation in the delivery of healthcare is contained by two main factors. Primarily, the majority of
the graduates are females, which is highly commendable, but only a small fraction of them enter the profession.
Thus, the huge public subsidy incurred in their education has a negative social return.
Secondly, those admitted in medical institutions on rural domicile wish to stay in big urban centres and
use connections to avoiding postings in the rural districts. Thus, the two sources of disparity-gender and a
rural-urban-divide remain unaddressed despite substantial i nvestment.

Table 5 . 1 2: Medical Personnel in Sindh (Public) ( 1 97 5-20 1 5)

Health
Year Doctors Nurses LHV technicians Radiographer
technicians
1 975 926 415 1 07 14 95
1 980 969 436 1 35 15 1 05
1 98 5 1 ,758 607 158 13 82
1 990 7,2 1 3 837 220 13 295
1 995 7,702 1 ,343 218 II 1 ,027
2000 7,953 1 ,639 306 11 1 ,369
2005 6,626 1 ,5 8 1 406 11 -

20 1 0 7, 1 45 I , 565 464 - -

20 1 5 7,990 1 ,630 786 - -

Source: The figures fo r 1 975-95 have been taken from Bureau of Statistics, Development Statistics of Sindh, Karachi, Plan n i ng and
Development Department, Government of Sindh, various years; Bureau of Statistics, Health Profik, Karachi, Planning and Development
Department, Government of Sindh, various years.

Table 5 . 1 2 shows a continuous increase in the number of doctors, nurses, and LHV technicians. The population
to doctor ratio has improved significantly but nurses are still in short supply. Technicians are now getting places
in the system. Two distinct trends are visible from this data. The number of doctors has appreciably gone up
almost eight times in the last thirty years, but there was a downward movement from 1 99 5 to 200 5 . This has
reversed because of the growth of private colleges. This may be increasing the number of doctors, but professional
competence and adequate training according to accep t ab l e standards remain open to serious questions. Most
of these colleges are driven mainly by profit with little attention to the quality of instructions.
The number of LHV assistants, operation theatre (OT) technicians, dais, and lab assistants continuously
increased, which is a positive sign as they serve as the backbone of an efficient and responsive healthcare delivery
system.
1 02 T H l. FC:Ol\ 0 ,\ lY OF I\!ODER'.\' S I '.\: D H

PRIVATE SECTOR
The private sector has assumed the role of a leading provider of prima ry. secondary, d i agnostic, pharmacy, and
ambulance services. fifty- nine per cent o f private hospitals of the countr\', which run for profit, are located in
Sindh. The p r ivate healthcare p rovision now encompasses a full range o f medical and demal services. Private
clinics arc expensive s i n ce they operate a t market prices, yet they are preferred because the al ternative, i.e. public
sector, su ffers from a number of weaknesses. In rural areas. unqual ified practitioners, quacks, compounds, fa i rh
healers, and hakeems d o mi n a te the scene as rhe poor cannot a ffo rd to pay for rhe services of q u a l i fied, privare­
p ractisi n g doctors. The i n t roduction o f rhe public-private i n i t iative over the last several years i s begi n n in g to
divert pati cms towards governmem c l i n ics, d ispensaries, healrh u n i ts , and health centres.
The private health sector is d i vi ded i n to profit a n d non-pro fi t ventures. The province also consti tutes the
largest network of not-for-profi t health services. Private healthcare has a strong foot i ng in urban areas. Attempts
to set up cli nics in rural areas have met wirh limited success but as rural incomes rise, there would be an increased
demand fo r prh·ate clinics and dispensaries.

NaN-GOVERNMENTAL ORGANISATIONS (N GOs)

KGOs ha\·e contributed i m menselv to i n c reasing access o f rhc poor to healthcare. Edhi Foundation, which has

communication system. The I n d u s Hosp ira! and the SI U T pnwide free services to those who cannot afford
the l a rgest ambulance service in Pakistan, has con trib uted immemely and is complememed w i th an efflciem

medical care. rn F.d h i Foundation runs the world's largest ambulance service and so do many oth ers including
Aman fou ndation, Chhipa ere.
The N C O s are b u i ld i n g and ram p i n g up specialised wards o r u n i ts in p u b l i c-sector hospitals. This i s
a posi tive move a s a majori ty o f t h e p o o r t u r n u p ar these hospitals rarher t h a n visiting t h e charitable o r
p hilamhropic faci l ities.
Other active organisations in rhis field include rhe Marie Sropes Soci erv, Pakistan Vo l u mary Health and
Nutrition :\ssociario n ( PAVH NA) , Fire Protection Associ,Hion of Pah,ran ( F PAP) , Healrh a n d Nurrirional
Developmem Society ( HA N D S ) , Thardeep. H ealth Oriemed Pm-enrivc Education ( HO P E ) , a n d H e a l th
Education l .ibrarv for People ( H EL P ) . S i m ilar!;" A K H S P is operating in secondar;' maternal care and prim ary
health care.
Some of rhe >JGOs are engaged in raising awareness for social issues. Aahung is an organisation rhar focuses
o n improvi ng reproducti\·e heal th. War against Rape (WAR) is producti\·e in raisi ng awareness regarding sexual
violence. Aurat Foundation concemrares on the role of women in poli tical and governance spheres.

Health Expenditures
Under the Eightcc:nth Amendment, rhe rcs p onsi b i l itv of health ""ls del egated to the p rovinces. This has resulted
in a gradual increase in budget allocation for this secto r. The rota! spend i ng o n health j umped from P KR 8 . 2
billion i n 200 5-0G t o P K R 4 8 . 4 b i l l io n i n 20 1 5- 1 6-a six-fold increase m·er ten \'ears. Most o f the budget was
incurred on recurring expenditure. The prm·incial de\'elopmenr spending for the healrh sector j umped from !'K R
2 , 3 3 5 m illion in 200 5-0(1 t o P KR 8 , 3 6 8 m i llion in 20 l 5- 1 6 . ' ' ' I n c reased expenditure in r h e absence of adequate
governance and managemem mav not i m p ro\·e healthcare del i 1 en· services particularlv to poor scgmenrs of
the population. Therefore. the Gm·e rnment of Sindh's i n i t iati\·e o f public-private parmcrship deserves ckN:
scruri m·. Benchmark i nd i cators should be established against \1·hich progress in achieving performance indicators
i s regularh- measured. m o n i tored, and course correction made where neccssan-. Prevemive healthcare faci l i t i es
including potable d ri n king 11 ater a n d sanitation facil itie> should be allocm:d adequate resources and given equal
 Table 5 . 1 3 : Sindh Health Budgetary Estimates and Expenditures ( i n PKR Mi llion)
( 1 970-7 1 to 20 1 5- 1 6)

1 970-71 1 975-76 1 980-81 1 985-86 1 990-9 1 1 995-96 2000-01 2005-06 2010- 1 1 20 1 5- 1 6

Total Health 53.425 1 32.727 77.445 8 1 1 .66 I ,469.02 2,97 1 .78 4 , 1 28 . 3 1 4,965 . 36 1 4,265 . 8 J 66, 503.90
Recurrent 26. 5 6 1 65.227 7.025 347.66 1 ,098.02 2,2 1 4 ..)0 3,734.98 4, 1 70.3(1 I 0 , 786. 5 7 5 4 ,090.%
Development 26.864 67.5 70.42 464 37 1 757.48 393.33 795 .00 3.479.24 J 2,4 1 2 . 9 5
Percentage share of Budgeted Recurrent and Development Expenditure (%) ·-·-

1 970-71 1 975-76 1 980-80 1 985-86 1 990-9 1 1 995-96 2000-01 2005-06 20 1 0- 1 1 20 1 5- 1 6

···--

Total J OO 1 00 1 00 1 00 1 00 1 00 1 00 1 00 J OO 1 00
Recurrent 50 49 9 43 75 75 ' 84 76 81
·-
)()

Development 50 'i i ') J 57 25 2 'i 10 J6 24 I ')

Actual Spending
1 970-71 1 975-76 1 980-8 1 1 985-86 1 990-91 1 995-96 2000-01 2005-06 20 1 0-1 1 20 1 5- 1 6
--
Actual Tena! Spending 6 1 . 1 4292 7.25 NIA 3 9 1 .% I , 1 98 . 1 3 2,293.24 3 ,327.99 8 ,244.68 1 3.32 1 .64 48.473 . 27
Recurrent NIA NIA NIA 346. 5 8 1 070. 1 2 2 1 1 8. 1 7 32 J J .()j 5,909 . 8 1 9,458.95 40, 1 0 5 . 7.)
Development NIA NIA NIA 4 5. 3 7 1 28 . 0 1 1 75.07 I J 6.% 2334.865 3 ,862.69 8 ,367.54
Actual Spending as a Percentage of Budgeted Figures (%)
1 970-71 1 975-76 1 980-8 1 1 985-86 1 990-91 1 995-96 2000-0 1 2005-06 20 1 0- 1 1 20 1 5- 1 6
Percentage of Actual
NIA NIA NIA 48 82 77 81 1 66 93 7.l
Total Spending
I Percentage nf Actual
NIA NIA NIA 1 00 97 % 86 1 42 88 I 74
Recurrent Spending
:r:
Percentage of Actual
NIA NIA NIA 10 35 23 30 294 111 67 ""'
Development Spending >-
'-l
Source: Finance Departmen t, Finance Budget Book, Government of Sindh, various years. :r:

0
\,;.)
1 04 T H E ECONOMY OF M O D ERN S I N D H

attention. The crowding our of healrh managers' time and financial resources in the form of curative health
facilities is one of the main reasons for the relative neglect of tackling the challenges of malnutrition, child and
maternity health, family planning etc.
The following has been achieved in the period 2008-09 to 20 1 1 - 1 2 :

• The Hepatitis Control and Prevention Programme was initiated, which included vaccinations, treatment
of afflicted patients, additional laboratories, awareness on a large scale, and training of staff. As many
as 4 . 572 million people were vaccinated, of whom 0 . 7 5 million were children. Around 93 ,664 patients
were treated for Hepatitis B , C:, and D .
In different secondary and tertiarv care hospitals, 43 specialised units \\'ere builr a n d 2,800 o f the health
staff \\'as trained to improve service delivery in Sindh.
The Public-Private Health Initiative (PPHl) was established in 2007. Ir operates i n 2 1 districts, and
manages 1 , 1 3 5 health facilities comprising 6 5 1 B H Us, 34 M C:Hs, 429 dispensaries, 9 RHCs, and 1 2
other facilities. Its performance over tht' years has made some diffrrence owing to cost-saving techniques,
efficient management, and strict mon itoring. PPHI has a long list of satisfied patients who are highly
impressed by and indebted to its proficient services. PPHI ensures that it is well-stocked with equipment
such as X-ray machines, which allows for speedy diagnosis and treatment. The rates of antenatal and
prenatal care, OPD attendance, and del ivery coverage are a testament to PPHI's performance in improving
the healrh of rural Sindh. It has confronted urban bias and removed the need for the locals to visit big
cities for medical check-ups. It is a successful example of a public - private partnership.
Expanded Programme of lmmunisation, Tuberculosis Control Program me, Malaria Control Programme,
and HIV/AID S Control Program me rook place.

Table 5 . 1 4: MDG Health Goals and Actual Outcomes as of 20 1 4

Indicator Sindh (20 1 4) MDG Target

lnfanr mortal it1· rate (deaths per 1 ,000 live b i rt h s) 82 52

Child mort a l i tY rare (under 5-mortalin) 1 04 40

Prop o r tio n of fulk immunised children aged 1 2-2.J months .) 5 >90
Ladv he.ii th workers coverage (as a percentage of the target population) 'i2. 3 ' 1 00
Proportion of children 1 2-2.) months immu nised agai n s t measles 'i 2 . 7 >90
Children Under 5 who suffered from diarrhoea in the last .10 days 28.4 ** <10
Maternal�10nality ratio ( pe r 1 00,000 live births) 21 4'** 1 40
_ -
Proportion of b i rths attended by skilled b i rth .mend.rnrs h 'i . 5

29
>90

Contraceptive prevalence rare 55

Total ferti!itv rate 4 2. 1

Antenatal care coverage (at least once) 79.7 1 00
· Percenta ge of women aged 1 5-49 wars who were visit,·d b1· lad\· health \\otkers d uring rhc past three months.
"' "' Percenragc of children with d i arr ho e a , under age fh e i n the L1\t 2 weeks .
. . . Refer to r a hlc 5.2.

C mT r n m e n t of Sindh and United Nation\ Development P ro g um m e , Rrport on the stt1tu:; of the Millennium Development GotJls
Source: Cowrnmcnt of Sindh and United Nati o m Iln dopmc·nr Program me, Si11dh ,�fultipll' !11rlirator Cluster Survey 2014, Karachi,
20 1 5 :
Sindh, K.uachi. 20 1 2.
 HEALTH 105

The report o n MDGs-Sindh, published in March 2 0 1 1 , for almost all the indicators observed that some o f the
districts performed far better than the others, and yet the crux of the problem was due to an urban bias. This
was persistent even in districts which produced good results.
A trend analysis showed fluctuation in the immunisation rates, where 'between 1 99 1 and 1 999 immunisation
coverage increased, declined, and then picked up again'. 4 0 However, the report concluded that the pace was not
sufficient for the MDG targets to be met. Furthermore, a majority of the districts showed disturbing cases of
diarrhoea along with underweight children.
Disparity between rural and urban areas was also highlighted in this report. The performance in big cities
such as Karachi and Hyderabad, and to some extent Nawabshah and Sukkur, has been relatively better due to
the availability of quality health services and generous funds.
It was also pointed out that social factors influence child health and the provision of child care. Literacy
levels, gender disparity, access to safe drinking water and sanitation, and food supply reflect the challenges
faced by the society. Moreover, the health sector suffers from weaknesses of its own which prevent execution
of its services with excellence. These include poor management and governance systems, chronic staff, absence
of complementary supervision techniques, unfair financial disbursement between urban and rural areas, and
weak decision-making and planning.
Pakistan has now adopted the SDGs which aim to end hunger and poverty by 2030. This is an opportunity
for the government to execute plans that could work towards the attainment of the following goals:

•
Maternal mortality to be reduced to less than 70 per 1 00 000 live births
•
Neonatal mortality to be as low as 1 2 per 1 000 live births
•
End to AIDS, tuberculosis, malaria, and waterborne diseases
•
Universal access to reproductive healthcare facilities

S u m m i ng U p
The poor health status o f Sindh's population, particularly i n rural areas, requires an integrated multi-sectoral
strategy. An integrated health sector approach includes family planning services, immunisations, emphasis on
nutrition, water supply, and sanitation. LHWs should be continuously trained better by focusing on their skills,
especially communication ones, to help in reaching out to poor families. Messages should be effectively targeted
in regional languages and must have the feedback mechanisms to respond to the concerns and questions of the
families/contacted. Parallel organisations, although some may claim that these are efficient, work in isolation
and are compartmentalised, making them neither cost effective nor efficient.
The devolution of primary, and secondary healthcare facilities to the local governments with adequate
financial and human resources would bring relief to the population as weil as the overcrowded tertiary and
teaching hospitals. The PPHI should be carefully monitored, and its impact and outreach evaluated, and the
initiative expanded to cover other districts. The provincial health department should concentrate on policy
making, and regulation along with developing options for health financing. The procurement of spurious drugs
is supported by public hospitals for supplying to the patients while genuine drugs procured for the public sector
are sold to private pharmacies, contributing to the loss of trust in the public health system. Therefore, high
out-of-pocket expenditures are incurred on drugs by the patients and their families.
Staffing of nurses and lady health workers in rural health facilities should be increased and incentivised to
help attract qualified personal to those areas. Uniform national pay scales have done a great disservice in the
way of promoting the rural population's access to health services. These scales have to be replaced by labour
market differentiated compensation packages, where scarcity premia are paid to those services in the rural areas.
] 06 THE ECONOMY O F MODERN SI:\'Dl!

The integrated health management information system ( I H 1\1 S ) should be updated, verified, and validated
to assist in plan ning and introducing missing services as well as setting up new health facilities in various parts
of the provinces.
Plans to educate and train nurses, technicians, radiographers, and pharmacists ought to be drawn in order
to fill in the current and future vacancies in the health system. Private medical colleges should be screened and
those below par should be closed down.
The b udget allocations have to be revisited in terms of salary and non-salary components. The present ratio
of 6 5 : 3 5 does not leave much scope for enhancing the quality of services rendered. A large portion of the salary
component is pre-empted by the general and support staff� some of which is not required but employed only
on political considerations or h u manitarian grounds. The salary saved from the attrition and non-replacement
of this tvpe of staff can be diverted to finance non-salary expenditures.