Health — a much-ignored sector

With the recent dengue outbreak, one is forced to question our national priorities. Health expenditure in Pakistan constitutes a mere 0.54 per cent of the GDP and has fallen over the last 10 years. Not only is public health care identified with poor and inefficient service delivery but it is grossly substandard at the primary care level. In reality, the provision of quality health care depends most importantly on good governance. If this lesson is not learnt fast enough, epidemics like the recent dengue outbreak are likely to continue and possibly increase over time.

Like many developing countries, Pakistan has an extensive network of publicly operated primary health care facilities that were mostly built during the 1980s and 1990s. While this dramatic expansion improved physical access to services, the utilisation of these facilities and the quality of care they provide are in general disappointing. Take the case of Punjab: a recent survey by the provincial government reports that about 75 per cent of the population is within half an hour of the nearest health facility. Of those, about 57 per cent report that the nearest is a government facility. In rural areas, this percentage is higher at 62 per cent. With such a large population within easy reach, the government should be able to exercise great control over the health management of the province. Still, about 70 per cent of the population uses the private sector to cater to its health needs. Why? I find that there are three glaring shortcomings that have gone unaddressed.

First and foremost, the primary health system suffers from low patient confidence. A basic health unit (BHU), which is the most critical primary health care facility at the district level, only manages to attract an average of 35 patients per day. These BHUs serve a population of 10,000-25,000 each. In Punjab alone, there are 2,535 BHUs. If we take attendance as a proxy for patient confidence in this extensive network, we see modest faith in the public health system.

Second, it has very high medical staff absenteeism. Some of the highest vacant positions are found in positions of medical officers and sanitary inspectors. These two positions are the most important ones at the level of a BHU, which is the first stage where disease and potential health risks can be stopped. Without clarifying the roles, responsibilities and relations of the medical staff and without restructuring the human resource management policies to attract and retain talented medical personnel, the facilities will remain without motivated medical professionals.

Third, the health management information system is ‘data driven’ rather than ‘action based’. Its significance cannot be overlooked, simply because any policy or planning is dependent on correct and timely information. Most of the data is of poor quality. The health worker has little motivation to ensure quality, since there is rarely any feedback on the reported data. It is important that health providers receive timely and accurate information to make evidence-based decisions rather than the ill-informed actions that take place following a crisis.

Experiences from other regional countries have shown that by increasing the level of community involvement (information flows from both ends), promptly filling up vacant posts of health care professionals and improving accountability, the state can contribute to better decision-making within the health system. These priorities are mutually reinforcing and they are affordable.

So far, the realisation that primary health forms the base of the health pyramid has been a motivator for policymakers and politicians to allocate resources for its promotion. In Pakistan too, following the principles of Alma Alta Declaration 1978, of which Pakistan is a signatory, the public health care system is primary-care focused. It has been given top priority within the National Health Policy of 2001, but while the policy document has formulated multiple plans of action to integrate processes of capacity building and implementation in its ‘Health for All’ vision, it appears to be either overambitious or inadequate in some of these key areas.

Published in The Express Tribune, October 28^th, 2011.