By Zubeida Mustafa
WHILE lamenting the dismal performance of the health sector in Pakistan, the State Bank’s Annual Report 2004-2005 identifies the factors for the poor health status of the people. It lists them as “poverty, inadequate and inefficient allocation of resources, malnutrition, unhealthy living environment and unequal distribution of health facilities”.
The health indicators in the country are shameful and the main cause of consternation is the fact that Pakistan is a richer country than many others whose people are healthier than ours. Thus Pakistan stands at the bottom rung of the ladder in South Asia in many sub-sectors of health. Take the case of infant (IMR) and under-five mortality rates (U-5MR). In 2003 they were recorded as 74 and 98 per thousand live births respectively. These were much higher than those for our other South Asian neighbours. Following us were Bhutan and India with an IMR and U-5MR of 70 and 87 respectively. This speaks volumes about how much the Pakistani state and society care for their women and children.
Another worrisome aspect is that the poor health status of the people does not seem to cause much concern to policymakers who can, if they want to, change the situation. They make no serious effort to formulate and implement a feasible health policy that addresses the major health problems of the people. Neither do they think it is important to allocate sufficient resources to this sector to upgrade health facilities and expand them to meet the needs of the people, especially the poor.
Thus in 2002 (the year for which the UNDP gives statistics in its latest Human Development Report) the government earmarked only one per cent of the GDP for the health sector. The private sector spent 2.1 per cent. This ratio between public and private sector spending does not reflect well on the government’s priorities because in a country where nearly a third of the people live below the poverty line public sector spending on health care should have been higher. The way things stand at present, it is clear that a small privileged class enjoys the luxury of medical care in times of illness. Moreover the absolute amount spent on health has unfortunately declined. Per capita spending fell from $80 in 2001 to $62 in 2002.
A visit to public sector hospitals which are bursting at the seams is a real eyeopener. The general indifference towards the patients there is astounding as is the corruption that allows dishonest personnel staffing the health facilities to siphon off the funds that are actually meant for the poor. Small wonder that patients are asked to bring their own medicines, bandages and sutures if they want to be treated. The bulk of the hospital budget is spent on the salaries of the staff.
Given this dismal state of the health facilities it is strange that the government fails to understand the significance of preventive medicine and the relationship between health and environment. This failure is amply evident in every walk of life. How many people have ‘sustainable access to an improved water source’ in the country? By cloaking the issue of clean water supply in these ambiguous terms the UNDP arrives at the impressive figure of 90 per cent in Pakistan. But we don’t have to be reminded of the high incidence of diarrhoeal diseases in the country which testifies to the quality of water a majority of people are receiving and perforce drinking.
The situation in respect of sanitation is no better. Unfortunately those at the helm have failed to understand the importance of cleanliness for good health. Open sewers euphemistically called storm water drains, garbage heaps that seem set to swallow the human habitations in their vicinity, industrial waste, air pollution, noise pollution and man-made ecological disasters have a direct impact on the physical and mental health of people.
Now that the state has absolved itself of the responsibility of health care of its citizens in an age when the marketplace reigns supreme, the price of this neglect of environment has to be paid by people themselves. They shell out huge amounts to get themselves treated by health practitioners with costly drugs. If they are too poor to afford the cost of treatment, they visit the quacks and are chronically ill until death brings them relief.
The State Bank report links bad health to poverty. It cites a National Human Development Survey (2003) that found that 55 per cent of the poor and 65 per cent of the very poor were ill. True, malnutrition is a major contributing factor to disease and poverty leads to malnutrition. Besides the poor are forced to bear the brunt of insanitation and unclean water. They live in crowded conditions and fresh and clean air is not their prerogative either.
The report rightly stresses the need to focus on preventive measures to reduce the incidence of illness along with the expansion of health facilities. It calls for not only an increase in financial allocations to the health sector but also emphasises the “efficient utilisation of funds” to optimise the benefits from investment in the health sector.
There are two other factors that the State Bank report fails to take note of which could make a lot of difference to the health of the people. One is education. It is important that just as poverty has been linked to ill health, illiteracy and poor education should also be linked to disease and malnutrition. Not only are the majority of our people illiterate, an even larger bigger number are ignorant and unschooled in the basic principles of hygiene, nutrition and exercise. That can be attributed to the failure of our education system and the electronic media. Whenever a concerted effort has been made to disseminate messages pertaining to health education and information, a dent has usually been made. Thus the campaigns to administer polio drops, immunise children against preventable childhood diseases of childhood and reduce the family size have created an impact as follow-up surveys have shown.
Why can’t the government launch similar campaigns for sanitation and environmental protection? The answer is obvious. The brunt of the responsibility will fall on the government to provide the services it motivates the people to use. For instance, when people are asked to have polio drops administered to their children, it is the health department that has to arrange for the immunisation facilities. If the government were to appeal to the people to keep their neighbourhoods clean, it would be obliged to arrange for garbage collection and sewage disposal. This being an ongoing job unlike polio days which come periodically, it is not surprising that the authorities shirk their responsibility.
The second factor that the State Bank report fails to note is the stress that living in this country causes the people. On the one hand is the uncertainty and the feeling of not having control over one’s circumstances that creates a lot of strain for people. Be it economic insecurity — the fear of losing one’s job, the inability to cope with inflation, and the erosion of one’s savings owing to factors beyond one’s control — or the physical hardship of coping with the irregularity in the provision of civic utilities, or worse still the psychological trauma caused by the breakdown in law and order, robberies, murders and terrorism, these affect a person’s health causing mental disorders or psychosomatic illnesses.
The tragedy is that the state, which is responsible for creating many of these conditions that lead to ill health, does not consider it its duty to provide succour to the ill. What we have is a system where the survival of the fittest is the rule of the game.