Is it really health for all?

By Zubeida Mustafa
Source: Dawn

THE Alma Ata message of ‘health for all’ has at long last reached the policy planners in Islamabad. Prime Minister Shaukat Aziz has said that the government’s health strategy was focused on the prevention and control of diseases, provision of maternal and child health care and ensuring nationwide outreach of public health facilities. These are indeed laudable goals and have been demanded by health professionals for decades now.

At a time when there has been a palpable shift in the government’s policy from the public to the private sectors in the areas of health and education, social justice demands that the basic health and education needs of the people should be met because that is the fundamental human right of all.

In the health sector, this should pose less of a challenge if the government undertakes its responsibilities conscientiously and with integrity. But regrettably, this has not been done — the prime minister’s statement notwithstanding — and the failure to follow a vigorous preventive approach while withdrawing support to the curative side of medicine has inflicted enormous suffering on the people.

A policy that focuses on preventive medicine is expected to address the factors which are the basic cause of many diseases. Thus public hygiene and sanitation, clean water supply, an effective immunization programme for children, nutrition for the vulnerable groups, and, above all, a dynamic and innovative approach to health education should form the underpinning of the government’s health policy.

While all this may not incur an exorbitant expenditure as a curative medicine policy would, it definitely calls for greater integrity, vision and a holistic outlook towards health. It also involves the participation of a massive number of people from different departments in different tiers of administration that makes checks and control more difficult.

The mere fact that the government has failed to make even a slight dent in this sector shows how little has actually been done. Take the case of sanitation, the key factor that determines the state of a people’s health.

It is strange but the fact is that we have proceeded to manufacture and test the nuclear bomb that requires a massive amount of money and expertise but have still not been able to discover the art of lifting garbage and keeping our cities clean. We do not know how to lay sewerage lines correctly, treat sewage — it is normal for us to let untreated effluent flow into the sea and rivers — and prevent atmospheric pollution.

We cannot eliminate mosquito breeding grounds and protect our people from malaria. We have even stopped doing what was done routinely before. Probably the water agencies are not even aware of disinfectants, such as chlorine, or of filter plants to clean the water supplied to the people.

Why are we then surprised when the prevalence of diseases directly caused by unhygienic conditions keeps rising? We don’t need to be given statistics collected by epidemiologists to know that rabies cases are on the rise as pye dogs roam freely in our towns and cities, new viruses are emerging from the mounds of garbage left uncollected and causing diseases unheard of before (haemorrhagic fever being a new entrant) and water-borne diseases are fast sapping us of our vitality and productivity.

Then there are more specific health measures that call for the intervention of health professionals, such as the Expanded Programme on Immunization and reproductive health care. The data in these fields is quite shocking. The Expanded Programme on Immunization has provided protection to only 53 per cent of the children against the six preventable diseases of childhood. Polio, which was to be eradicated by the year 2000, is still occurring though mercifully the number of cases has gone down.

The administration of BCG, which is important if the problem of tuberculosis in childhood has to be addressed, has hardly picked up. In 1994, four million infants received the vaccine. In 2004, 4.8 million had been protected against TB, not a very impressive increase in a decade. As a result, 80 per 1,000 infants die within the first year of life, whereas 103 children of 1,000 live births die under five years of age. The maternal mortality rate is 500 per 100,000 live births. We have worse figures than even South Asia’s average infant and under-five mortality rate that is 66 and 91 per 1,000 live births respectively.

If the government is seriously committed to promoting preventive medicine it will have to reorient its approach to all civic issues and sectors of national life — even if they are seemingly very trivial. Its policies will have to be health-centred. For instance, garbage collection should be treated as a political issue because it should be linked directly to public health. Environmental pollution also needs to be so perceived.

Whether it is the KPT stacking huge piles of coal in the open for the sea breeze to carry coal dust to blacken the lungs of Karachiites or the traffic police turning a deaf ear to the noisy rickshaws and fumes-emitting buses, or the factories which release untreated effluents into the soil under the ‘watchful’ eyes of the environmental protection agencies, the authorities will have to address these questions as serious health hazards under a programme of preventive medicine.

Since it is now quite plain, and the prime minister has also confirmed it, that the government is disengaging itself from tertiary health care, its responsibility of promoting preventive health has increased manifold. After all, it is highly immoral to expose people to health hazards, let them fall ill for no fault of theirs and then expect them to die in silence because they cannot pay for expensive medical treatment.

As it is the health expenditure has barely increased as the percentage of GDP. It was 0.6 per cent in 1994-95, rose to 0.7 per cent the following year and then went down to 0.6 per cent in 2004-05.

Moreover, the increase in corruption has ensured that the money being pumped into projects ostensibly to protect people’s health is siphoned off by dishonest functionaries.

There is also the failure of the authorities to take preventive measures that are cost-effective. For instance, there are no screening campaigns which would ensure a health checkup for every child in school or every factory worker or the inhabitants of every low-income mohalla in a city. It is only thus that serious ailments are detected before they become serious threats to life.

The most ironical aspect of the preventive health programme in Pakistan is the nutrition plan. The government calculates the nutritional status of the population in terms of the caloric availability of food which the Economic Survey, 2004-05 informs us has gone up from 2,529 to 2,534 per capita with protein availability going up from 65.3 gm/capita per day to 65.8. The Survey very proudly states, “The supply of calories and protein is well above the average Recommended Daily Allowance.” But availability is different from actual consumption. Is the 34 per cent of the population living below the poverty line receiving enough nutrition?