November 28, 2012

The Politics of Health in Pakistan

The health of a nation can be measured by its health care system while the health care system hinges on the country’s national health policy and strategy. The country’s political leadership is the principal driving force behind such policies and strategies. If you want to know how strong the country’s political leadership is, look at its key health indicators and you will get a fast answer to your question.

Pakistan is in the list of developing countries where the health care system is still on life support. India has joined the international community in waging a war against global health issues but unfortunately, we are not yet able to control vaccine preventable diseases like polio in our own backyards. It’s a shame that sixty-five years after independence, the total immunization coverage is still at a low level. Diarrhea, pneumonia and malnutrition are still the main causes of deaths among children under five. Hundreds of thousands of pregnant women still die because of severe bleeding, infections and high blood pressure.

The question on everybody’s mind is: isn’t the government doing enough to tackle these problems? The answer is most likely no. Health and education are the most neglected sectors in Pakistan. Look at the state budget of last five years and see what percentage of the federal budget is allocated for health care in the country.

The health sector reforms will never take place until the political leaders and other policy makers understand the problem, express their viewpoints and act accordingly. As a public health professional, I will bring to light some key health issues that I noticed during my professional career in Pakistan.

Human resources for health are identified as one the core building blocks for a health care system. The biggest challenge facing the health care sector is the serious lack of human resources. The model of putting the qualified and right people in the right place has never been used in Pakistan. In order to get a holistic view of a situation,let’s take the health ministry as an example. Country’s public policy making lies in the hands of non-health professionals (like ministers, secretaries etc). You will hardly find qualified health professionals and researchers at relevant health ministries.
Meritocracy does not exist anywhere in the country. Recruitment, transfer and promotion processes are based on several factors such as political affiliation, ethnicity, class, religion, bribes etc. Because of the dismal situation, many qualified health professionals are either leaving the country or joining the private sector and as a result the human resources for health (HRH) challenge does not get better.

The other major challenge facing the health sector is the prevalence of technically unsound, politically misleading and financially nonviable decisions that are undoubtedly affecting the health care sector to an unbelievable extent. In developed countries, health professionals and policy makers make evidence based decisions regardless of the political consequences. They can turn down any health project if it does not meet required criteria. In Pakistan the situation is other way round. We follow “decision based evidence making process”. If a political leader comes to a decision to build a new 200-bed hospital in his or her constituency then no one at the health ministry will determine whether there is a genuine need for such a big hospital in the community? Ideally, a technical team from the relevant health ministry should visit the proposed area and prepare a comprehensive feasibility report before the construction is kicked off. I have seen many hospitals in Pakistan that are either vacant or underutilized.

Equity is another burning issue that is weakening the health care system in Pakistan. Resources are not evenly distributed across the country. If you compare a district hospital of Punjab with a similar caliber hospital in Gilgit Baltistan, then you will notice a huge difference. The former will have a good building, well equipped emergency department, lots of sophisticated equipment (like CT scan), ambulances and many specialist doctors. The later one will be consisting of a few rooms and will be at a disposal of a medical officer. You will neither find basic equipment (like x-ray, ECG) nor necessary life saving drugs.

Poor governance in the health sector has also led to misdirected spending of funds. Corruption in the procurement of medicines and equipment has defamed the health sector. There is no independent procurement body that can ensure transparency, quality and reliability. Political leaders and other influential people at the Ministry of Health issue contracts to their own friends and relatives and as a result hundreds of millions of dollars disappear each year.

On the other hand, hospitals are being provided with poor-quality equipment and medicines, both substandard and counterfeit. The government will be less worried about the situation if patients die after consuming substandard medicines. Just recently, seventy patients at Punjab Institute of Cardiology (PIC) died after consuming substandard medicines. Unfortunately till now, no action has been taken to identify and punish the culprits.

The Pakistani media has an important role to play to bring about a change in the country. It is said that media reflects society and holds up mirror to country’s political leaders. However, both electronic and print media have not yet truly pinned down health issues in Pakistan. Sit in front of the television and observe how many talk shows or discussions on key health issues have been on the air? Get up in the morning and go through the newspapers and see how many articles have been published on health and nutrition related problems?

The political leadership, health professionals, researchers and media should work together to strengthen the health care system in Pakistan. International agencies like World Health Organization, World Bank, UNICEF and USAID should play a larger and critical role in health care reform as internationally recognized, viable and uniform health policies are the real need of the hour in Pakistan.

                               Published in "The News International" on November 28th, 2012