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IN Pakistan, the most important aspect of well-being is also the most neglected. In its 70-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 66 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.
Behind the dismal numbers lie heartbreaking stories of lives ruined and cut short due to the unavailability of affordable and quality healthcare. An unhealthy population with severely diminished capabilities cannot substantially contribute to the economy. Health indicators suggest that it is the lack of accessible healthcare — not terrorism, drones or the energy crisis — that is the greatest adversity facing Pakistan. And although healthcare is certainly linked to problems of corruption and security, there is no reason why healthcare should not be made an immediate priority, rather than placed on the back burner of policy discourse.
The fact that Pakistan is a developing economy with resource limitations is not an excuse when we look to other low-income countries that have made great strides in healthcare in the last few decades. The experiences of these countries provide illuminating lessons that should be applied in Pakistan.
We spend only 0.9pc of our GDP on health. Only two countries have a lower ratio of GDP to health spending.
Thailand and Mexico are examples of two developing countries that have made political commitments towards universal healthcare with very encouraging results. In 2001, the Thai government introduced a ‘30-baht universal coverage scheme’ that covered the entire population with a guarantee that a patient would not have to pay more than 30 baht per visit for medical care.
Thailand also adopted an innovative measure to promote public accountability through the creation of the ‘Health Assembly’, a regular meeting where citizens voice feedback and complaints on the health system. Mexico established a ‘System of Social Protection in Health’ in 2003, which includes a public health insurance scheme that has steadily expanded insurance coverage with a package of comprehensive health services to 52 million Mexicans.
While health indicators in India as a whole are lamentable, some states such as Tamil Nadu perform remarkably well. For example, Tamil Nadu’s infant mortality rate is 22 per 1,000 births and maternal mortality is 97 per 100,000 births, significantly better than many other states in India (and all provinces in Pakistan).
A distinguishing feature of Tamil Nadu is the extent to which its citizens actively lobby public officials for the provision of health and other public services. This culture of protest, studied closely by researchers such as Vivek Srinavasan, involves regular activism on the part of the public to ensure that government-run health facilities and health programmes are functional and accountable.
At least two lessons may be drawn from the experiences of other countries that excel in the provision of healthcare. Firstly, government-supported universal healthcare is attainable and affordable, even in low-income countries, so long as it is made a political priority. Countries such as Thailand and Mexico have met the healthcare needs of large swathes of their populations by improving public health services and providing public insurance schemes.
Secondly, an informed and activist public can play a crucial role in mobilising public health systems to serve the needs of the population. When healthcare systems are transparent and accountable, citizen advocacy can influence government policy and healthcare governance with positive results.
In Pakistan, implementation of health policies devolved to the provinces in 2010 after the 18th Amendment to the Constitution. In theory, this should create new opportunities for public engagement with provincial and local government officials for the provision of public health services. In reality, however, provinces are yet to realise the fruits of devolution.
In Sindh, for example, public health facilities are in appalling condition, plagued with staff absenteeism and shortage of essential medicines and equipment. What is lacking, but is certainly worth aspiring to, is a ‘culture of protest’ around access to government healthcare to ensure that medical staff is present for duty and medicines are available in public health facilities. Democratic action is essential to ensure that the administration of public health by provincial governments is effective and equitable.
In their book, An Uncertain Glory: India and Its Contradictions, economists Amartya Sen and Jean Dreze urge that issues of healthcare be brought closer to democratic politics. We in Pakistan must not accept the state of health as inevitable since this mindset only encourages government complacency and indifference. Instead, our public officials and elected representatives must be pushed to make health the central political issue of our time.
The writer is a lawyer practising in Karachi.
Published in Dawn, June 27th, 2016
