THE DAILY TIMES
Attainment of universal health coverage in Pakistan: issues, opportunities and challenges
Dr Ghulam Nabi Kazi
December 13, 2019
As we celebrate the International Universal Health Coverage Day of the United Nations today, we need to be cognizant of certain facts in our country’ context.
Health policy development took off with a slow start after the creation of Pakistan. In fact, during the first decade of our existence, we did not go beyond convening three national health conferences, in 1947, 1951 and 1956, respectively. The records of these deliberations may still be lying in some archives somewhere but they seem to have had no direct bearing on healthcare provided to the people.
The first impetus to health policy making came with the induction of Lt Gen W A Burki as health minister in October 1958. The country’s first Medical Reforms Commission was set up under Lt Col Illahi Bakhsh in 1959. The colonel had the distinction of being the personal physician of the Father of the Nation as well as the first indigenous principal of the King Edward Medical College in Lahore, from 1947-1954. He had published a monumental work exceeding 2,300 pages on modern medical treatment in 1956. Not surprisingly, the commission he headed was concerning ‘medical reforms’ as opposed to ‘health reforms’.
A positive aspect of the commission may have been the approval of rural health centres for smaller towns or town committees in the Third Five-year Plan in 1961. That gave rise to a new tier of health facilities as until then there were only civil hospitals in the larger cities and district council dispensaries. Basic health units at union council level came much later during the eighties and nineties. The lady health workers also came up in the nineties to bridge the gap between the communities and health facilities and to provide elementary healthcare at the doorsteps of the communities.
The then president Zulfikar Ali Bhutto announced the People’s Health Scheme in 1972. If the scheme could be summarised in three words, those would be Universal Health Coverage (UHC). An important element of the scheme was generic drugs.
These two documents may have helped to shape the strategic vision of the World Health Organisation towards Primary Health Care as enunciated in the Alma Ata Declaration of 1978, preceded a year earlier by the Essential Drugs List under the phenomenal guidance of WHO’s best known director general, Dr Halfdan Mahler. The seventies and eighties were ‘hot’ times for health. There were a lot of developmental efforts in Pakistan with construction of several hospitals and health facilities.
The Alma Ata declaration was beginning to have an impact, at least the realisation of health as a human right was beginning to take roots. Passing through the Harvard School of Public Health in Boston during the nineties, I would never fail to be struck by the inscription,as declared in the constitution of WHO, on its outer wall: “The highest attainable standard of health is one of the fundamental rights of every human being.” Whether or not that goal was attainable in the USA or elsewhere, those words hit you in the gut.
Reverting to Pakistan, while the right to health is not enshrined in the constitution, the right to life is protected. National Health Policies were developed in 1990, 1997 and 2001. An advanced draft of another policy was on the anvil during 2010, when the Eighteenth Amendment was enacted and passed, effectively winding up the federal ministry of health and distributing its residual federal functions to a dozen ministries and institutions.
It was only in 2013 that the government of the caretaker prime minister, Mir Hazar Khan Khoso, re-established the National Health Services, Regulation and Coordination division, ostensibly on the insistence of his minister for science and technology, Dr Sania Nishtar. The elected government that followed appointed a minister of state and later full federal minister to supervise the division, setting aside apprehensions that the newly elected parliament may roll back the newly established division/ministry.
At the turn of the millennium and with the advent of the 21st century, some positive vibes were sent out to all the developing countries globally. There was talk of certain major donors writing off loans provided their grants were utilised for social sectors, or more specifically, in pursuit of the eight Millennium Development Goals, to be achieved till 2015. That placed health at the centre of human development as three were directly related to maternal and child health and communicable disease control, while the rest were about tackling the social determinants of health, such as extreme or hunger poverty, education, gender and environment, while fostering partnerships.
Such a global paradigm shift in priorities must have been disconcerting or even alarming for the arms lobby and the merchants of death that flourish and thrive on hatred, disharmony, enmity, conflict or even wars to protect their interests. Their response came on September 11, 2001, as the United States of America came under attack on what we call 9/11. Unfortunately, our part of the world had to bear most of the brunt of the fallout in the aftermath of that tragedy, hampering our efforts to focus on social sector targets, particularly those relating to health.
Subsequently on January 1, 2016, the United Nations came up with the Sustainable Development Goals (SDG), more than doubling the MDGs (17), and going beyond the deprivations of poverty to include issues such as peace, stability, human rights, climate change, employment opportunities and good governance, in the hope of seeing a better world over the next 15 years or so. Furthermore, the targets were made much more demanding.
In attaining SDG 3, we need to ensure that by 2030, the maternal mortality ratio is reduced to less than 70 per 100,000 live births, end preventable deaths of newborns and children under 5 years of age, with neonatal mortality to at least 12 per 1,000 live births and under-5 mortality to at least as low as 25 per 1,000 live births, end the epidemics of AIDS, tuberculosis, malaria, hepatitis, neglected tropical diseases, water-borne diseases and other communicable diseases. In addition, we have to reduce by one-third the premature mortality from non-communicable diseases, strengthen the prevention and treatment of substance abuse and harmful use of alcohol, halve the number of deaths and injuries from road traffic accidents, ensure universal access to sexual and reproductive health care services, including family planning, and achieve UHC, including financial risk protection, access to quality essential health care services, and access to safe, effective, quality and affordable essential medicines and vaccines, while ensuring that no one is left behind.
That’s quite a tall order given the sub-optimal health, nutrition and population indicators that are improving although not at the pace required, with more to be done like intensifying implementation of WHO’s Framework Convention on Tobacco Control, supporting the research and development of vaccines and medicines for communicable and non-communicable diseases, substantially increase health financing and recruitment, development, training and retention of the health workforce, while strengthening the national capacity for early warning, risk reduction and management of health risks.
The Global Conference held during October 2018 in Astana, Kazakhstan, reinforced the belief and efficacy of WHO’s Primary Health Care approach that alone provides a legitimate pathway and roadmap for UHC. The other significant point to be noted vis-à-vis SDG 3 is that UHC is both a means as well as the end for meeting all the targets. In short, the benefits of this largest mission ever undertaken by Pakistan’s Health Sector would be prodigious, and the sooner we attain the targets, the better.
Nevertheless, three years have gone by since the SDGs were announced without a significant change in health financing or spending. As per the last Economic Survey of Pakistan covering the nine-month period from July 2018-March 2019, the cumulative health spending of the federal and provincial governments stood at 0.53 percent of GDP. So where do we go from here?
Firstly, the issue is not simplistic; it requires careful planning using an inclusive and participatory approach. More importantly, it requires the support of not just the economic ministries but the other social sectors as well. In a resource-constrained environment, cost-effective mechanisms eschewing duplication and wastage are only possible if all stakeholders work in tandem towards their commonly shared goals. To cite an example, it is better to ensure the provision of safe drinking water rather than invest on the treatment of typhoid or its vaccines.
Road safety requires a systematic approach with health being just one partner. What is warranted in such a situation is the affirmation from the top leadership that attainment of UHC is a foremost priority for the country. Such a gesture from the top is necessary to convey the right message to the relevant stakeholders and reinforce their confidence in the health system. It will also provoke the economic ministries to translate the political commitment for such a huge initiative into concrete budgetary allocations, both in the recurrent and development budgets.
Secondly, attention needs to be paid to our human resources for health (HRH) situation, which constitutes the backbone of the entire system. While Pakistan falls in the list of the most deprived HRH countries, there is also an acute imbalance within the core professionals required. While WHO requires four nurses for every doctor, as of 2017, Pakistan had 205,152 doctors while the total nurses, lady health visitors and midwives were around a half of those, at 104,046 in a population of 208 million.
With regard to WHO’s required rate of 4.45 core professionals per 1,000 population to reach SDG 3, we currently stand at 1.5 or one-third, that too with a lopsided balance. This indicates that we need 722,000 more nurses and midwives to attain our targets, a figure that has been approved by federal and all provincial health ministers a couple of years ago. We will also need specialist doctors in fields that are grossly inadequate, such as psychiatry, in addition to a host of other cadres such as health managers, health planners, health economists, statisticians, epidemiologists, medical records technicians, information technicians, medical assistants, dieticians, nutritionists, occupational therapists, medical imaging and therapeutic equipment technicians, optometrists, ophthalmic opticians, physiotherapists, personal care workers, speech therapists and medical trainees, not to mention general management and support staff.
It is also imperative to ensure that health staff of all cadres are evenly distributed across the country without any discrimination whatsoever, contending with issues such as absenteeism in the peripheral areas; low motivation of staff; a highly unregulated private sector; a significant proportion of female doctors dropping out after graduation; a predominant preference for posting in the larger cities; lack of a proper gender mix or skills-mix, particularly in peripheral health facilities; lack of defined packages of minimal quality standards at the primary and secondary levels of care in most provinces; lack of a referral system; and several other systemic issues that impede the working of the health system, which otherwise comprises of a huge network of hospitals and health facilities. These shortcomings require more a change in mindsets than economic resources. This, in turn, makes it imperative to redress institutional imbalances and poor quality health professional education leading to inequities and inconsistencies across the system. The importance of regular and structured continuous professional development for all cadres also cannot be underestimated.
Thirdly, our traditional thematic areas in health need to be revisited. While for the greater part of our existence we have focused on reproductive, maternal, neonatal and child health and communicable disease control, including tuberculosis, HIV/AIDS, malaria, viral hepatitis B & C, dengue and others, chronic conditions like diabetes, cancer, cardiovascular diseases and chronic respiratory diseases have always taken a backseat despite their enormous burden of premature mortality and the existence of a long-approved National Action Plan for Prevention and Control of Non-Communicable Diseases (NCDs). Even though NCDs have been part of every health policy drafted or approved in the last two decades, there appears to be a major unexplained gap between policy and implementation in this area.
Diabetes can lead to serious damage to heart, blood vessels, eyes, kidneys and nerves. Pakistan needs to institute appropriate programmes on a war footing at the provincial and district levels. At an operational level, such programmes may include capacity building of primary care physicians, paramedics and outreach workers; surveillance of diabetes trends; behaviour modification; early detection through screening to identify diabetics and high risk pre-diabetics; access to effective therapies to prevent life threatening complications; and nutritional surveillance focusing on overweight children. Now some headway is being made in imposing taxation on sweetened sodas, however, breast milk substitutes and certain notorious fast foods could be added to the list.
Provincial and district governments can also be proactive in promoting environmental action like increasing playgrounds while enhancing access to the right foods such as fruits and vegetables with a meaningful collaboration with food and beverage industries. The National Diabetes Survey 2016-17 has shown that over 35 million people above the age of 20 years in Pakistan suffer from diabetes; this should serve as a wake-up call. The risk factors in our population include malnutrition, rapid urbanisation with unhealthy lifestyle changes, genetic factors, and a singular lack of awareness leading to erroneous lifestyles.
There are very few preventive cardiology interventions in the country although more women die of heart disease than cancer. Despite this alarming estimated NCD prevalence, provincial and district governments appear ill prepared to either cope with this major epidemic through systematic efforts or measure the economic and social impact of major NCDs in Pakistan. Seen from the purview of competing health priorities, such data could provide incontrovertible evidence for mainstreaming of the prevention and control of diabetes, cardiovascular diseases and cancers in public health planning.
Pakistan is also lacking in a national population-based cancer registry to collect, analyse and interpret data on all cancer cases in a country through a sustained, ongoing and systematic effort. Many cancer prevention measures are cost-effective and inexpensive and therefore, even the poorest of countries can take effective steps to curb the cancer epidemic, save lives and prevent unnecessary suffering. Cancer prevention planning is largely based on a systematic assessment of cancer risk factors at the country level, with the objective of obtaining good quality and comparable country-level data. These data are required for priority-setting and evidence-based allocation of scarce resources. Around 40 percent of all cancers are preventable, while early diagnosis and treatment can help in saving and/or improving quality of lives.
Cancer prevention can also be integrated with other prevention programmes as the predominant risk factors for cancer include tobacco use, unhealthy diet, physical inactivity and obesity, which also fuel the epidemics of other chronic diseases such as diabetes, cardiovascular diseases and respiratory diseases. The current prime minister of Pakistan, Imran Khan, has already devoted over two decades of his life to cancer treatment; it is now time to walk the extra mile towards effective cancer control and prevention.
While Pakistan has ratified WHO’s Framework Convention on Tobacco Control and has been actively pursuing the strategies contained therein, it has made minimal progress on implementation of WHO’s Global Strategy on diet, physical activity and health or other programmes aimed at eliminating the most widespread occupational or environmental carcinogens.
Primary prevention in the form of tobacco and areca nut control alone can bring about a significant reduction in malignancies in both sexes. Tobacco taxation and regulation of tobacco exports can also help tremendously in this regard. Early detection and treatment of cancers can change the entire pattern of mortality statistics. A primary focus on improved awareness concerning the causation of cancer and practices such as self-examination of the oral cavity, breast, and cytology-based screening for high-risk cervical cancer population segments can be most useful as well.
Fourthly, effective, transparent and accountable governance of the health sector needs to be established, particularly at provincial and district levels with highly trained managers in place on all pivotal positions for a sustained period of time. Information systems containing vital data relating to communicable diseases, non-communicable diseases, maternal and child health outcomes and HR need to be beefed up with timely and error-free reporting that can be used for decision making.
Standardised job descriptions, proper career structures and opportunities for personal and professional growth, particularly for the marginalised cadres such as midwives and lady health visitors should be made more congenial to attract more women, particularly in peripheral areas. It is important to retain all cadres of outreach staff such as LHWs, LHVs, vaccinators, community midwives and family planning workers within the system to enhance the provision of primary care services to peripheral communities, particularly within sparsely distributed populations, and to ensure skilled birth attendant assisted deliveries if facility based deliveries are not possible due to any reason.
Fifthly, health equity should be regarded as the basis for all interventions in the march towards UHC. Health insurance needs to be replicated across the board in its true spirit, interim poverty reduction subsidies such as BISP and health cards should be provided to all those living below the poverty line. Patients must have access to other social safety nets such as Zakat and Baitul Mal to avoid catastrophic expenditures on health. In case anyone is left behind, the system in effect fails that person.
Sixthly, all national nutrition surveys since 2002 have been wake-up calls. The prevalence of stunting, wasting, underweight, obesity and low-birth weight babies have now reached alarming proportions. Affirmative action is warranted though community action and treatment of severe malnourishment in the health facilities. All provincial governments should take up nutrition stabilisation issues in children and expectant mothers with the seriousness it deserves.
Seventhly, as decided by the Council of Common Interests, population welfare needs to be assigned a very high priority with a meaningful integration of efforts by the health and population sectors. As far as practicable, all health sector facilities should include population control in their service delivery packages to avoid any unmet demand in this regard.
Lastly, forging effective collaborative partnerships and coordination mechanisms engaging local community, national and international stakeholders, and pursuing the aid effectiveness approaches will be most rewarding. These will include technical partners from the United Nations such as WHO, UNICEF, UNFPA, FAO and WFP, and the major donors such as the World Bank, USAID, DFID, JICA, CIDA and others.
A whiff of fresh breeze in this entire scenario is the development of an ambitious programme for nursing and midwifery in Pakistan. According to plans agreed with the provincial governments, the diploma courses are being abolished, and replaced with bachelor programmes in nursing and midwifery.
Generous grants as a one-time support will enable the provinces to cater for better infrastructure, international faculty, scholarships, skill development laboratories and libraries, and pick up the thread after a five-year period that will enrol close to 126,000 students in graduate programmes and over 1,900 students in masters programmes while 12 will do their doctorate. The project has been approved by the Central Development Working Party and is awaiting approval of the executive committee of the National Economic Council at a cost of PKR27.908 billion through direct government spending without any donor support. It concertises the vision of the government of Pakistan and the agenda is purely home grown. A detailed implementation plan for the project has also been prepared with the support of all the relevant stakeholders in the provinces and has the potential to rapidly turn around our HRH situation in the run-up towards SDG 3.
To conclude, as is evident, the UHC will not be easy to accomplish in a huge and diverse country like Pakistan. All governments and their respective partners will need to work in concert and at a pace of effort never witnessed before. The main drivers of this passion and commitment will need to emanate from the topmost leadership of the country. It is a huge opportunity that needs to be availed in the hope that our children secure a healthy environment and can enjoy a better quality of life. Everything said and done, it is well worth the effort.
The writer is a senior public health and public policy specialist
Posted by Doc Kazi on 2019-12-14 04:54:49