August 2004, Volume 54, Issue 8

Special Communication

The Grave Problems being faced by our Health Sector

H. A. Gezairy  ( Regional Director of WHO Eastern Mediterranean Region )

Introduction

The collaboration of WHO with the Government of Pakistan has existed ever since the foundation of the organization, and has been faithful to the first article of its constitution devoted to the attainment by all peoples of the highest possible level of health. This collaboration was further strengthened with the establishment of the WHO country office in Pakistan in January 1960. Through this close partnership, WHO has been contributing to health sector development in Pakistan, while the experience gathered from this and other countries has played a positive role in shaping the strategic policies of the organization. WHO has always designed its strategic interventions in a country on the basis of the national priorities., using the "Health for All" approach as one of the critical guiding principles for health sector development.

During the sixties, the emphasis was laid on building infrastructures for health, and the establishment of a large network of Rural Health Centers or RHCs at town committee level was an effort to take health care services closer to the community. These first level care facilities started to deliver for the first time a catchment area based service with a real potential to transform the scope and quality of the health care system.

The seventies can be remembered as the decade of PHC, when the international public health movement led to the Alma-Ata Declaration in September 1978. The Alma-Ata declaration strongly reaffirmed that health is a state of complete physical, mental and social well being, and not merely the absence of disease or infirmity. It stated that health is a fundamental human right, and that the attainment of the highest possible level of health is a crucial social goal globally whose realization requires the action of many sectors other than health. This charter defined the range of the essential services required, and stressed on universal access, while endorsing the concepts of equity, community participation and intersectoral action.

Although Pakistan has expanded its PHC services and brought about a tangible reduction in mortality and morbidity, yet the desired impact has fallen short of our expectations, largely due to insufficient investment of financial and human resources in this vital sector. Indeed, a meager investment of the public sector of less than 1% of GNP cannot be expected to significantly transform the health care system in Pakistan or in any country. Furthermore the district health systems were unable to cope with the immense tasks on their hands and it is only now that these systems are being reinforced.

In 1993, a joint survey by the Ministry of Health (MoH) and WHO revealed that the level of utilization of Basic Health Units that were set up during the eighties was as low as 23%.

The study clearly indicated that although these facilities were relatively closer to the community than Tehsil and District hospitals, yet their social distance was grossly under estimated. As a result of this survey, WHO proposed in 1993, the establishment of a new cadre of Primary Health Workers at the grass root level, in order to ensure that health education, reproductive health, vaccination, control of diarrhea and acute respiratory infections (ARI), promotion of safe water and sanitation and other dimensions of PHC could be made easily accessible to the local community. It needs to be realized that the lack of success in any country in achieving health for all targets, does not signify a weakness in the PHC concept, but stems largely from a lack of commitment in these countries to a health system based on PHC. We strongly believe that "Health for all" through PHC remains the most viable strategy for the health care system in the 21st century.

The initiative of the Lady Health Workers (LHWs) was jointly launched in late 1993 in union council Tamman of district Chakwal in the Punjab as a pilot intervention. Young rural females with a high school certificate were inducted in an intensive community based PHC training programme to subsequently deliver essential PHC services to the households of their residential catchment areas, and bridge the existing gap between the community and first level care facilities. The programme was scaled-up in early 1994 throughout the country. The strength of the LHWs cadre has now reached 70,000, and the government is working to further raise this force to 100,000 with recognized success in delivering essential PHC interventions. We strongly hope that the current devolution process will seriously take advantage of this expanded district health system network with added financial and human resources allowing it to operate effectively.

Through this network of PHC based district health system, Pakistan has every opportunity to avert the havoc caused by the few childhood communicable diseases and surmount reproductive health problems that presently account for most of the 280,000 infant and 16,000 maternal deaths every year.

In the area of disease control, we all recall the legacy of a remarkable partnership in the eradication of Small Pox, from which Pakistan was finally declared free in 1974. The last case of small pox occurred on 14 October 1974 in a 6-year old girl of district Multan and the country was certified on 17 December 1976. Through this joint intervention, Pakistan and WHO were able to make a permanent impact on the public health sector of Pakistan by completely wiping out a disease that entailed a very high morbidity and mortality over the centuries.

The experience of small pox was followed by the gigantic task of eradicating guinea-worm disease. Pakistan took a great lead in this regard by working closely with WHO to eradicate the disease, thus obviating its negative impact on the working capacity of farmers and the less privileged rural population. The eradication campaign was launched in 1986 and met with absolute success in six years time; the last case being detected from Dera Ismail Khan in the NWFP during 1993.

This public health victory gave a tremendous impetus to our conviction that given political commitment, community support and a determined health sector, Pakistan can surely make significant gains in public health. I still recall with pride my handing over of the eradication certificate to the then Prime Minister of Pakistan on 7th October 1996 at Lahore.

Another partnership legacy in public health rests with the launching in 1978, of the vaccination programme redirecting the small pox teams into what later became the National Expanded Programme on Immunization (EPI), targeting vaccine preventable childhood killer diseases. The programme expanded gradually, with major up-scaling in 1983, under the jointly launched "National Accelerated Health Programme", where the EPI was implemented along with two other major interventions, namely diarrhea control through ORS and TBAs training on safe and clean delivery all aiming to reduce both infant and maternal mortality. There is incontrovertible evidence now that the ORS constitutes one of the most practical and cost-effective technologies for child survival of the 20th century.

Prior to the launching of this programme, tens of thousands of children were dying from Whooping Cough, Measles, Diphtheria and Tuberculosis while over 15,000 children were being disabled by Poliovirus every year.

This was further compounded by the diarrhea fatality and escalating maternal mortality. Today all the three services are successfully integrated into the first level care facilities although their utilization remains sup-optimal. Through our technical partnership, the scope of EPI was further enhanced by the addition of the hepatitis B vaccine in 2001, aimed at significantly lessening the burden of chronic liver disease including liver cancer in our population.

Another major communicable disease where we are working closely is Tuberculosis control. Pakistan ranks sixth amongst the 22 high burden countries. WHO has introduced the strategy of Directly Observed Treatment Short Course (DOTS), a viable and cost-effective methodology for TB control, endorsed already by 155 countries. The programme is able to curtail the infectivity of TB patients after only two months in the majority of cases, and after a further 6 months, 85%-90% of patients using the DOTS strategy are cured at an average treatment cost of US$15.

As we commemorate the World TB Day today, we salute the Government of Pakistan for having declared Tuberculosis as a national emergency exactly three years ago and the momentous strides taken since then resulting in around 60% DOTS coverage throughout the country, with Sindh having universal DOTS coverage. With this rapid pace of implementation, Pakistan can minimize both the risk of multi-drug resistance, and avert the dual epidemic of HIV and TB. However, our immediate challenge now is to take DOTS implementation to the tertiary care institutions, semi-autonomous institutions and the private health sector through developing partnerships as the present incidence of 171/100,000, yielding close to 250,000 new cases every year, poses a major public health. The theme for this year's World TB Day "Every breath counts - Stop TB Now" needs to be viewed in this context.

An old re-emerging communicable disease in Pakistan is Malaria, where in 1998 the traditional control strategy was replaced through our common effort by the Roll Back Malaria initiative, where several landmark strategies entailing early diagnosis, prompt treatment, the promotion of insecticide treated nets or ITNs, the use of residual spraying, promotion of health education, early detection and response to epidemics, building of local partnership for and promoting operational research to improve the efficacy of these interventions were introduced. It is pertinent to note that malaria affects over 30% of the districts of Pakistan and the falciparum ratio is rising in many districts, implying greater risk to outbreaks and serious morbidity and mortality outcomes. The public health community and the government need to work extensively to ensure that this disease is effectively controlled through inter-sectoral action and sound implementation of RBM strategies.

In the area of Nutrition, WHO has supported two complementary strategies, firstly by integrating nutrition education and promotion programmes into PHC services to improve the knowledge, skills, and behavior of mothers and households thus reducing the high level of malnutrition amongst mothers and young children as well as the high incidence of low birth weight.

Secondly by promoting food fortification interventions that aim at universal access to micronutrients, through fortification of wheat with iron and folic acid, salt iodization and fortification of ghee with Vitamin-A. In collaboration with the Ministry of Health and the Planning Commission, WHO has completed a successful pilot programme on iron fortification, while conversely efforts for the iodization of salt are stagnating and the ghee fortification law is not sufficiently enforced. These interventions need to be scaled-up nationwide to maximize their large-scale proven beneficial impact as the recently carried out National Nutrition Survey has revealed a huge prevalence of stunting, wasting and low birth weight babies in addition to micronutrient deficiencies.

Breast feeding is an ideal food for the healthy growth and development of infants, while, inappropriate feeding practices lead to infant malnutrition, morbidity and mortality. Improper practices in the marketing of breast-milk substitutes and related products also contribute to these major public health problems. Through our joint collective effort, the Government of Pakistan has appreciably endorsed in 2002 the WHO/UNICEF strategy that protects exclusive breastfeeding for the first six months of life.

In the area of Safe Blood Transfusion, WHO and the MoH are striving together to avert the escalation of Hepatitis B, Hepatitis C and HIV/AIDS in Pakistan. These efforts have resulted in the promulgation of a national ordinance on the subject in October 2002. Today the 650 hospitals offering blood transfusion services are morally and legally required to ensure comprehensive screening. However, we should stress that sufficient level of awareness and capacity building should support this legislation.

The strong correlation between poverty and health has gained wide recognition around the globe. However, the lack of adequate inter-sectoral support continues to haunt the health system, where a tangible coordination between health and other health-related sectors such as education, water, sanitation, and rural development interventions are necessary to enhance health development. Taking account of this reality, WHO and the Government of Pakistan have jointly launched the Basic Development Needs (BDN) programme, an intervention promoting community participation and inter-sectoral action on health and health related issues, and focusing on the essential needs relevant to the quality of life of the population.

This experience has gained considerable momentum whereby several districts of Pakistan have incorporated this innovative approach in their district level development programmes. The BDN initiative substantiates the PHC concepts of community participation and intersectoral action and recognizes them as necessary components for achieving the desired gains in public health. BDN has emerged as a bridging endeavor that links health to the Millennium Development and PRSP goals of the country, which we strongly endorse.

In the field of Human Resource Development for Health, WHO is a long-term strategic partner with sustained technical support in all health fields. Our technical assistance is extended to undergraduate programmes in medical, nursing and paramedical institutions in curriculum development, teacher training and institution building. In this context, the concept of Community Oriented Medical Education (COME) is being promoted to produce graduates professionally equipped to address priority public health needs of the population. We salute the Pakistan Medical and Dental Council for reviewing the medical education curricula and endorsing the COME conceptual framework in its deliberations. However, we have yet to traverse a long distance when it comes to the implementation of these curricula in a manner conductive to our real aspirations. To achieve viable problem based learning and community based education, medical colleges should develop a strong linkage with the national health system, as there is a growing pressure on them to address the true health needs of the population. This requires a full time and professionally dedicated faculty with an attractive incentive package for meaningful operational research and their career development.

WHO is equally active in Continuing Medical Education (CME), working with its national collaborating centers, spearheaded by the CPSP with the objective to keep the medical community up to date with the latest medical practices and technologies. We commend the ongoing efforts of the Ministry of Health in establishing strategic guidelines for CME until the day it becomes a requirement for the registration of health professionals.

The threat of Non-Communicable Diseases (NCDs) is real, as they account for 38% of the total burden of disease in Pakistan. WHO is working closely with the Government to prevent and control cardiovascular diseases, cancers, diabetes mellitus, mental health disorders accidents and violence. We have sufficient evidence to the health gains inherent in promoting healthy lifestyle, balanced nutrition and the prevention of major risks to health.

In this regard, we commend the recently concluded tripartite partnership between the MoH, Heartfile NGO andWHO for the prevention of NCDs at the grass root level, where the LHWs and BDN community strategies will spearhead the intervention. We also congratulate the Government of Pakistan particularly its Ministry of Health for endorsing the Mental Health Act, which constitutes a bold, and a rightist health reform initiative. One of the major interventions to control NCDs is the Tobacco Free Initiative, where we are jointly working together since 1998, to revert the growing burden of this epidemic conscious of the fact that 36% of adult males and 12% of adult females are tobacco users. It is evident that epidemics of lung cancer and cardiovascular diseases cannot be mitigated without direct and tangible efforts against tobacco use.

It is gratifying to note that this joint effort has resulted in the promulgation of a national ordinance in 2002 made effective from July 2003 that prohibits smoking in public places and thereby protects the health of non-smokers that has been adopted by the present legislature.

In the area of pharmaceuticals, the WHO essential medicines are based on the principle of ensuring universal access to life saving drugs of assured quality and properly used has been endorsed by the Government of Pakistan, offering unprecedented opportunities for public health. We are presently working with the Ministry of Health in establishing the technical basis for a National Drug Regulatory Authority to further substantiate the relevance of essential drugs as a vital component of the health care delivery system.

The national programme of traditional medcine is an area from where Pakistan can derive both health benefits and economic gains, and avert the negative effects of some herbal medicines. Our long-term collaboration in this area led in 2003 to the notification of a national policy on traditional medicine supported by a rich original research generated by public sector institutions in collaboration with the Hamdard Foundation.

WHO is working with Pakistan in the area of health research to promote evidence for objective decision making in public health in partnership with PMRC and other research and educational institutions.

We can confidently assert that these interventions have improved our capacity to develop sound health policies and carry out strategic planning in all fields of public health.

Before concluding, I must take account of the noteworthy success in disease eradication. In 1988, the international community and WHO recognized our collective capacity to eradicate all the three wild viruses that causes Poliomyelitis, a disease that was permanently disabling 350,000 children every year in our globe. This fight was effectively joined by Pakistan in 1994 where all the four globally endorsed strategies were put into action.

In the year 2000, we enhanced our efforts by endorsing the door-to-door immunization strategy. Despite the fact that Pakistan is currently one of the remaining six countries with indigenous Poliovirus transmission, yet the success cannot be undermined, as we have moved from over 15,000 cases per year in 1988, down to 103 cases in 2003. Furthermore, Pakistan has joined with the other remaining five countries in signing the global anti-polio declaration, pledging to make every possible effort to ensure polio eradication by the end of 2004. To completely wipe out this crippling disease, we require a high-level political advocacy, intensive social mobilization, active involvement by the district administration and effective technical implementation of the programme.

We must also take pains to complete the unfinished agenda of the Health Sector that includes addressing or averting the dual epidemic of communicable and non-communicable diseases that will constitute a real obstacle to socio-economic development, augmenting mother and child health facilities, improving the routine immunization coverage, making advances in vaccines development, reversing the growing trend of smoking and adopting a holistic approach to combat poverty.

I have no doubt that given a high level of governmental commitment, the health status of Pakistan's population will be significantly improved and a lot of preventable morbidity and mortality will be successfully averted at a point in the not-too-distant future to our immense satisfaction and WHO stands ready to support you.

Journal of the Pakistan Medical Association has agreed to receive and publish manuscripts in accordance with the principles of the following committees: