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Pakistan’s Healthcare Crisis – By Ramsha Zafar

By Dr. Ramsha Zafar
Physician/Internal Medicine
Freelance Writer

Pakistan’s Healthcare Crisis
پاکستان میں حِفظانِ صحت کا بُحران
ُपाकिस्तान का स्वास्थ्य सेवा संकट

“Healthy citizens are the greatest asset any country can have.”
“Physical fitness is not only one of the most important keys to a healthy body, it is the basic of dynamic and creative intellectual activity.” 
“There is no health without mental health; mental health is too important to be left to the professionals alone, and mental health is everyone’s business.”
“So many people spend their health gaining wealth, and then have to spend their wealth to regain their health.” 
“If your health is poor, you cannot enjoy life to the fullest, no matter how successful and wealthy you are.”
God has given us life as a priceless gift, hence we must take good care of our body, mind and soul.”

Good Health

Good health may be the most valued attribute of life. Daily, we express our concern for others by inquiring about their health and wishing them well. Material concerns are overshadowed when our own health is threatened; good health is recognized as essential for the pursuit of happiness. We all want to live a long life with ‘good health’. But what does that really mean? Clinicians often define ‘good health’ as the absence of disease. Indeed, modern biomedical research focuses on finding remedies for specific ailments, that, when absent, will yield ‘good health’. We can be healthy if we do not have a recognized disease but can also be healthy if we can manage a condition and look to live life to the full. Focusing on good health and what makes us well, rather than on bad health and what makes us sick, moves us to consider assets rather than deficits. People and communities have assets which determine their health, and these can be built on and strengthened. Looked at from this point of view we can see health as a public good, as something that everyone should work towards and the best attainable health as a human right.

A sorry state of affairs: 'Condition of healthcare sector deteriorating fast'

Health Care Crisis in Pakistan

A healthcare system is a structured assembly of resources and personnel aimed at delivering healthcare services tailored to meet the needs, goals, and satisfaction of a nation’s populace. With 195 countries worldwide, each endeavor to enhance health and lessen disease burden within the framework of global healthcare. Four prevalent models exist globally, amalgamating public and private facilities, and offering a compelling rationale for healthcare system operation.

Pakistan, the fifth most populous country globally with nearly 225 million people, faces numerous developmental challenges impacting its healthcare system. Pakistan is positioned at 122nd among 190 nations in the World Health Organization’s performance assessment.

Although there has been an increase in life expectancy from 61.1 years in 1990 to 65.9 years in 2019, Pakistan ranks 154th among 195 countries in the Healthcare Access and Quality Index, as per a Lancet study. Despite improvements since 1990, with the Healthcare Access and Quality index rising from 26.8 to 37.6 in 2016, Pakistan still ranks 164th out of 188 countries in terms of the United Nations Sustainable Development Goals and their attainability by 2030.

Pak-hospitals

IN Pakistan, the most important aspect of well-being is also the most neglected. In its 76-year history, Pakistan’s successive governments — civil and military — have not made health a priority. It is woeful that discussions around health policy receive little to no space in the agenda of political parties. And while the media tends to report heavily on specific heath-related crises — such as the spread of polio and child deaths in Thar — meaningful debate around the causes of abysmal health services is virtually absent.

The result of this apathy is appalling health indicators. The infant mortality rate in Pakistan is 68 per 1,000 births, compared to 38 in India and eight in Sri Lanka. Life expectancy in Pakistan for women is 67 years, as compared to 73 in Bangladesh and 78 in Thailand. The maternal mortality rate in Pakistan is 170 per 100,000 live births, in contrast to 30 in Sri Lanka and 20 in Thailand.

The indifference of Pakistan’s government to health is reflected in the fact that Pakistan spends a mere 0.9pc of its GDP on health. Only two countries, the Democratic Republic of Congo and Bangladesh, have a lower ratio of GDP to health spending.

Another indication of the government’s neglect is the fact that public expenditure on health accounts for a little over one-third of Pakistan’s total health expenditure. Pakistan’s citizens rely heavily on private healthcare, which they avail primarily through out-of-pocket payments. This is in stark contrast not only to the developed West, but also to developing countries such as Thailand and Sri Lanka, where public expenditure accounts for most of health spending. The poor quality of government provided health services in Pakistan is the major reason behind the large role played by the private sector in healthcare.

Spending a night at a government hospital showed me the state of healthcare in Pakistan

Beveridge model

Pakistan has maintained the British healthcare system, known as the “Beveridge model,” since its partition. This system operates with primary, secondary, and tertiary levels of healthcare.

Primary Health Care

Primary healthcare in Pakistan comprises basic health units, dispensaries, Maternal & Child Health Centers (MNCH), and private clinics at the community level. In Sindh, primary healthcare is supported by the government but managed by external private and non-government organizations like People’s Primary Healthcare Initiative (PPHI Sindh), Shifa Foundation, and HANDS. The government’s primary healthcare system is bolstered by 100,000 Lady Health Workers (LHWs) and an increasing number of community midwives (CMWs), among other community-based workers.

Secondary Health Care

Secondary healthcare includes tehsil and district hospitals, both government-run and some private hospitals. Treatment at government hospitals is provided free of cost.

Tertiary Health Care

Tertiary healthcare encompasses private and government hospitals equipped to perform minor and major surgeries. Most cities have two or more tertiary hospitals, including Class “A” military hospitals, offering free healthcare services and 24-hour emergency care.

Other Health Services

The government’s “Sehat Sahulat Program” aims to provide basic medical care to the lower class without financial risks. The Maternal and child health centers run by lady health workers, focus on family planning and reproductive health.

Quacks ruining the ailing humanity

Pakistan: Quacks make killing with 'cheap cures' | Pakistan – Gulf News

Quackery System

In Pakistan, the quackery system poses a significant challenge to public health and safety. Quackery refers to the practice of individuals falsely claiming to have medical expertise or qualifications and providing unauthorized or ineffective treatments to unsuspecting patients. This system thrives due to various factors, including limited access to qualified healthcare professionals, low health literacy levels, and cultural beliefs.

Quacks often operate in both urban and rural areas, setting up clinics or visiting patients’ homes, offering treatments for a wide range of medical conditions. They may prescribe inappropriate medications, administer injections without proper sterilization, or perform invasive procedures without adequate training, putting patients at risk of serious harm.

Despite efforts by regulatory authorities to crackdown on quackery, enforcement mechanisms are often weak, allowing quacks to continue practicing with impunity.

Collaboration between the Public and Private Sectors

Collaboration between the public and private sectors aims to provide optimal care. However, the healthcare burden has strained the delivery of quality services, particularly within the government setup. Over the past decade, healthcare expenditure has remained below the recommended threshold by the World Health Organization, with only 0.5-0.8% of GDP allocated to healthcare.

Universal healthcare in Pakistan

Health Infrastructure

Pakistan boasts a diverse healthcare landscape. It incorporates government facilities, para-statal health organizations, private sector entities, civil society initiatives, and philanthropic endeavors. Additionally, alternative and traditional healing methods enjoy widespread popularity across the country.

In 2011, Pakistan underwent significant constitutional reform through the 18th Amendment, leading to the dissolution of the Ministry of Health. Consequently, powers were decentralized, granting provinces greater authority over health infrastructure and financial matters.

The country’s health system is characterized by discrepancies in healthcare delivery between urban and rural areas, as well as a workforce imbalance, with insufficient health managers, nurses, paramedics, and skilled birth attendants in the periphery areas. Healthcare challenges in Pakistan also include inadequate budgetary allocation, shortage of medical professionals, substandard physical infrastructure, rapid population growth, counterfeit and expensive medicines, shortage of paramedical personnel and presence of unlicensed practitioners.

Pakistan faces numerous health challenges from infectious diseases to non-communicable ailments. Pakistan grapples with a multifaceted health crisis exacerbated by various socio-economic factors.

Challenges Encountered in Pakistan’s Health Sector

One of every 20 Britons of Pakistani origin suffers from hepatitis: NGO - Pakistan - DAWN.COM

Infectious Diseases

Infectious diseases constitute a significant component of the healthcare crisis in Pakistan. These diseases, ranging from endemic infections like tuberculosis and hepatitis to periodic outbreaks such as dengue fever and polio, exert a profound impact on the Pakistani population.

One of the primary reasons infectious diseases exacerbate the healthcare crisis in Pakistan is the country’s dense population combined with inadequate healthcare infrastructure. Limited access to clean water, proper sanitation, and healthcare facilities facilitates the spread of infectious agents, leading to heightened disease transmission rates. Additionally, factors such as poverty, overcrowding, and insufficient vaccination coverage contribute to the persistence and resurgence of infectious diseases.

Furthermore, the emergence of antibiotic-resistant strains of pathogens presents a daunting challenge to disease control efforts in Pakistan. Misuse and overuse of antibiotics, coupled with inadequate infection prevention and control measures results in the development and spread of drug-resistant infections, further complicating treatment and management.

Acute respiratory infection (51%)

Children, especially malnourished ones, are most vulnerable to ARI. The National ARI Control Programme initiated in 1990 halved the death rates among children under five in Islamabad within three years. In 2006, there were 16,056,000 reported ARI cases, with 25.6% affecting children under five.

Blood sample for hepatitis C virus testing — AFP/File

Viral Hepatitis (7.5%)

Hepatitis B and C epidemics are significant in Pakistan due to the overuse of therapeutic injections and syringe reuse in private healthcare. Pakistan’s Hepatitis B prevalence is estimated at 2.5%. The prevalence of Hepatitis C infection is 11.55% among adults. Pakistan stands second globally in terms of hepatitis C virus (HCV) infections, with approximately one in every 10 Pakistanis already affected.

Tuberculosis

Tuberculosis (TB) is an infectious disease caused by bacteria, primarily affecting the lungs. Pakistan’s TB prevalence is 348 per 100,000, with 276 new cases per 100,000 population. The country ranks fourth globally in multidrug-resistant TB prevalence due to delayed diagnosis and improper treatment.

Malaria (16%)

Malaria disproportionately affects lower-class individuals in Pakistan, with unsanitary conditions providing breeding grounds for mosquitoes. Reported cases surged after the 2022 floods, reaching over 1.6 million cases in 2022.

With Covid-19, healthcare workers are having to choose who gets a chance to live, and who will be left to die - Pakistan - DAWN.COM

Coronavirus

As of November 2020, Pakistan reported around 326,431 COVID-19 cases, resulting in approximately 7,000 deaths, with older individuals being the most affected. The transmission of the coronavirus in Pakistan occurs primarily through respiratory droplets when an infected person coughs, sneezes, or talks. Close contact with infected individuals and touching surfaces contaminated with the virus also contribute to transmission. Factors such as crowded living conditions, insufficient ventilation, and limited access to healthcare further facilitate the spread of the virus in communities.

Cholera

Cholera, a highly contagious bacterial infection, remains a significant public health concern in Pakistan. The country has experienced outbreaks of cholera, particularly during natural disasters such as floods, where contaminated water sources exacerbate the spread of the disease.

Dengue outbreak sets new record in Pakistan - Pakistan - DAWN.COM

Dengue

Dengue became endemic in Pakistan after its first reported case in 1994, with outbreaks occurring periodically. The spread of dengue fever in Pakistan is fueled by factors such as urbanization, climate change, and inadequate vector control measures, leading to increased mosquito breeding and transmission. Lack of public awareness and limited healthcare resources further contribute to the disease’s prevalence.

Measles

Measles transmission in Pakistan is fueled by factors such as low vaccination coverage, especially among vulnerable populations, inadequate healthcare infrastructure, and challenges in reaching remote areas with vaccination campaigns. Additionally, overcrowded living conditions and limited access to clean water and sanitation contribute to the virus’s rapid spread.

2 new polio cases in Lakki Marwat, 1 in Harnai bring total to 76 this year - Pakistan - DAWN.COM

Poliomyelitis

Pakistan and Afghanistan remain the only two countries with endemic wild poliovirus type 1 as of 2023.The spread of polio in Pakistan is primarily attributed to challenges in vaccination coverage, including resistance to vaccination campaigns due to misinformation and misconceptions, inadequate access to healthcare services in remote and conflict-affected areas, and difficulties in reaching high-risk populations. Additionally, the poliovirus can easily spread through contaminated food, water, and direct contact with infected individuals, particularly in communities with poor sanitation and hygiene practices.

Over 9,000 new HIV cases surface in Pakistan in 2023

HIV/AIDS

The spread of HIV/AIDS in Pakistan is driven by various factors, including inadequate awareness and education about the disease, stigma and discrimination towards affected individuals, limited access to healthcare services, including testing and treatment, high-risk behaviors such as unprotected sex and injecting drug use, and socio-economic disparities.

Infectious diseases not only exact a toll on individual health but also impose a significant economic burden on Pakistan’s healthcare system and society at large. Moreover, infectious disease outbreaks can disrupt economic activities, trade, and tourism, exacerbating poverty and hindering socio-economic development.

Non-communicable diseases (NCDs)

Non-communicable diseases (NCDs) pose a significant public health challenge in Pakistan, contributing to a substantial burden of morbidity and mortality. Common NCDs include cardiovascular diseases, cancer, diabetes, and chronic respiratory diseases. Factors driving the prevalence of NCDs in Pakistan include urbanization, sedentary lifestyles, unhealthy dietary habits, tobacco use, and air pollution.

Cancer survival rate increasing - Pakistan - DAWN.COM

Cancer

According to recent studies, the five most common malignancies in Pakistan are breast cancer (24.1%), oral cavity (9.6%), colorectal (4.9%), esophagus (4.2%), and liver cancer (3.9%).The majority of deaths in Pakistan were reported to be caused by breast cancer. Pakistan has the highest rate of breast cancer among all Asian countries, with roughly 90000 new cases diagnosed each year, of which 40000 die. Young women typically come with advanced-stage breast cancer, which has a detrimental impact on prognosis. Oral cavity and gastrointestinal malignancies remain exceedingly frequent in both genders. Lung and prostate cancers are far less common. Ovarian cancer also has a high incidence.

Inadequate Family Planning

Family planning programs in Pakistan face several challenges, including limited access to contraceptive services, and cultural and religious barriers. Additionally, conservative social norms and gender inequalities may hinder discussions and decisions related to family planning.

Maternal Mortality Ratio

The maternal mortality ratio in Pakistan stands at 154 per 100,000 live births as of 2020. Notably, it’s 26% more elevated in rural regions compared to urban areas. As per the 2019 Pakistan Demographic Health Survey, obstetric hemorrhage accounts for 41% of maternal deaths in the country, while hypertensive disorders contribute to 29% of these fatalities.

Role of Nutrition in Child Health

Nutrition plays a pivotal role in child health, yet both lack and excess poses significant challenges. Insufficient nutrition can lead to stunted growth, weakened immunity, and cognitive impairments, contributing to a child health crisis. Conversely, over-nutrition, often linked with excessive calorie intake and poor dietary choices, increases the risk of obesity, diabetes, and cardiovascular diseases from a young age.

Environmental threats

Environmental hazards such as ecosystem degradation, deforestation, accelerated industrialization, advanced technologies, vehicle emissions, and evolving lifestyles marked by excessive reliance on refrigeration, air conditioning, cosmetics, fragrances, and deodorants, contribute to the amplification of the greenhouse effect. This amplification is driven by the emission of gases such as CFCs, SO2, and NO2, resulting in ozone depletion in the stratosphere and heightened levels in the troposphere. These factors collectively lead to environmental pollution, global warming, and a rise in sea levels, posing imminent threats to both human and aquatic life. Droughts exacerbate health risks, including food insecurity, malnutrition, anemia, night blindness, and scurvy. Meanwhile, escalating temperatures heighten the threat of heatstroke, malaria, dengue fever, respiratory illnesses, and cardiovascular diseases.

In 2022, Pakistan experienced a devastating illustration of the health impacts of climate change through widespread flooding. This event submerged approximately one-third of the nation, impacting 33 million individuals, with children constituting half of the affected population. The floods inflicted severe damage on water infrastructure across the affected regions, compelling over 5.4 million people to depend solely on polluted water sources such as ponds and wells for their daily needs.

Lack of Quality Medical Education

Institutions responsible for medical, dental, and nursing education lack adequate resources and staffing. Medical graduates should be mandated to serve in rural areas for a year to address healthcare disparities. While community-oriented medical education is widespread in Pakistan, graduates need further orientation to instill a sense of commitment to their communities. Public health education requires more attention from policymakers and professionals to meet international standards.

Research in the Health Sector

Medical research lacks interest and focus, hindering scholars’ efforts to keep pace with global advancements. Research is inconsistently integrated into undergraduate curricula across medical colleges. Postgraduate students lack adequate training in writing medical research papers, presenting a challenge to producing high-quality research.

Human Resource Development

Human resource development in the health sector does not align with demand-supply dynamics. Priority should be given to in-service refresher training to enhance personnel skills. Advanced nursing services must evolve to meet community health needs and future challenges. Female nurses face social and moral threats in male-dominated environments, necessitating conducive work environments. The recruitment of male nurses should be considered to alleviate the challenges faced by female nurses. Salary packages and incentives for healthcare professionals do not match market rates, leading to a brain drain. According to the Pakistan Medical and Dental Council (PMDC), there are 118,160 registered doctors, resulting in a population/doctor ratio of 1,310. The number of registered dentists is 6,761, with a population/dentist ratio of 25,297. The total registered nurses are 33,427, leading to a population/nurse ratio of 4,636. This data underscores the scarcity of healthcare professionals in Pakistan, requiring urgent attention.

Report marks Afghanistan and Pakistan as the fastest-growing populations in the regions. — AFP/File

Population Explosion

The burden of an overwhelmingly growing population and its impact on socio-economic development is evident through several concerning health indicators:

  • Population quadrupled since 1947, reaching 156 million.
  • Population doubling time stands at 37 years, with the current growth rate recorded at 1.86%.
  • Unmet family planning needs remain high at 33%.
  • Total Government expenditure on health per capita is only 4%.
  • The contraceptive prevalence rate remains at 34%.
  • Alarmingly, the rate of low birth weight stands at 37%, indicating potential health risks for newborns and future generations.

— Photo/File

Future of Public Health

The future of public health requires concerted efforts from public health agencies, policymakers, and academic institutions to address key areas and enhance the quality of life for all citizens:

Medical Care: Enhancing access to quality medical services and promoting preventive care initiatives.

Biomedical Research: Investing in research to drive innovations in healthcare and disease prevention.

Strategic Planning: Developing comprehensive strategies to address public health challenges effectively.

Health Disparities Elimination: Implementing measures to reduce disparities in healthcare access and outcomes among different population groups.

Advances in Information Technology: Leveraging technology for data management, surveillance, and healthcare delivery.

Biotechnology: Harnessing biotechnological advancements for medical breakthroughs and disease control.

Health Services Regulation: Enforcing policies for the planning, development, and regulation of healthcare services and workforce.

Food and Drug Regulation: Ensuring the safety and efficacy of food and drug products through effective regulation.

Environmental Pollution Control: Implementing measures to mitigate environmental hazards and protect public health.

International Collaboration: Strengthening international cooperation and agreements for disease control and health information exchange.

Community Health Services Evaluation: Conducting independent evaluations to assess the effectiveness and quality of community health services.

Consumer Representation: Including diverse community voices in policymaking to address cultural, racial, and linguistic disparities and protect vulnerable populations.

Data Collection and Management: Improving systems for collecting, analyzing, and disseminating health-related data and resources.

Healthcare Financing: Developing sustainable healthcare financing mechanisms, including health insurance, to ensure universal access to care.

Workplace Safety: Promoting ergonomic practices and safety measures to protect the health and well-being of workers.

By prioritizing these areas and fostering collaboration across sectors, we can build a stronger foundation for public health and improve outcomes for communities worldwide.

Vaccination: Certain vaccines are obligatory for individuals residing in Pakistan, encompassing the Polio vaccine, BCG for childhood tuberculosis, Pentavalent vaccine (comprising DTP, Hepatitis B, and Hib) for protection against Diphtheria, Tetanus, Pertussis, Hepatitis B, Hib pneumonia, and meningitis, along with the Measles and Rotavirus vaccines.

Foreign Aid

Pakistan urgently requires foreign assistance from various organizations, encompassing financial aid, equipment, and cutting-edge AI technology, to combat its prevailing health crisis. The influx of resources is vital to bolster healthcare infrastructure, enhance treatment capabilities, and streamline diagnostic processes. With the integration of AI technology, Pakistan can significantly improve disease detection, treatment planning, and healthcare management systems, thereby augmenting the effectiveness and efficiency of its healthcare sector. By fostering international partnerships and leveraging technological advancements, Pakistan can emerge from its health crisis with strengthened resilience and enhanced capacity to address the healthcare needs of its populace.

Conclusion

Good health may be the most valued attribute of life. Daily, we express our concern for others by inquiring about their health and wishing them well. Material concerns are overshadowed when our own health is threatened; good health is recognized as essential for the pursuit of happiness.

The health crisis in Pakistan demands urgent attention and comprehensive solutions. With a burgeoning population, inadequate healthcare infrastructure, and limited access to essential services, the country faces multifaceted challenges. High rates of maternal and child mortality, infectious diseases, and non-communicable illnesses underscore the urgent need for improved healthcare delivery, strengthened public health systems, and increased investment in preventive measures. Addressing socio-economic disparities, enhancing health education, and promoting healthy lifestyles are essential to any sustainable solution. Moreover, tackling environmental degradation, water and food security issues and climate change impacts are imperative to mitigate future health risks. Collaborative efforts between the government, healthcare providers, civil society, and international partners are essential to address the root causes of the health crisis and ensure the well-being of all Pakistanis. A concerted, multi-sectoral approach is crucial to overcoming these challenges and building a healthier future for the nation.

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