Pakistan once again stands at major crossroads today. A nation of over a 100 million young, disillusioned people seems to be at war with itself. The political imbroglio of the last 11 months has taken an enormous toll on not just the economy and development activities but has pushed us to the brink of what appears to be an existential crisis. Pakistan today faces a perfect storm of complex forms of poverty: the poverty of assets and means, rampant inflation and food poverty but perhaps most damagingly, the poverty of hope. The brain-drain of young professionals these days easily exceeds the peaks witnessed during the darkest days of urban terrorism and political vendettas in the country.

To foretell the future of health in Pakistan, one must look at the past, which despite the regression hinted at above, is dotted with periods of progress and development. Pakistan began its journey at partition with an average life expectancy of about 50 years which has improved to 68 years from recent most estimates (likely over 80 among the relatively well-off sectors of the population).

Despite progress and gains in reducing high rates of maternal and child mortality, Pakistan’s key indicators lag significantly behind most of its neighbours. Of every 1000 children born in Pakistan today, some 80 ill-fated souls will not live to see their fifth birthday. Stunting rates among children exceed 40% and, in some regions, over 60% of all young children. There are vast disparities across and within provinces for basic services including immunization rates and healthcare. Even Afghanistan boasts of a more rapid reduction in child mortality over the last two decades.

Yet, the country did make remarkable progress in many areas of public health, often heralded by periods of stability and strong technical leadership within the relevant planning departments and ministries of health. The development of an integrated rural and district health infrastructure in the 70s and 80s with Basic Health Units and Rural Health Centers was a move with an explicit focus on reducing disparities.

The creation of a cadre of community-based health workers to provide family planning services and primary care in rural areas, was the brainchild of Benazir Bhutto — who established one of the first large scale community health worker programs to bridge the urban-rural gap upon her return from the Population Conference in Cairo in 1994. This Lady Health Workers (LHW) program has been the backbone of rural primary care for almost 30 years and led to notable gains in preventive and promotive strategies among marginalized rural women and children.

Despite limitations and enormous competition from India and Bangladesh, Pakistan boasts a healthy pharmaceutical sector today and is able to make much of its essential drug needs (although foreign exchange depreciation and regulatory challenges around drug prescribing have made things very difficult in recent months).

These investments and innovations are remarkable examples of major initiatives that did contribute to improvements in public health indicators, especially for women and children. The fact remains that the efficiency and performance of these programs has depreciated over time, often reflective of years of neglect and stagnation. To illustrate, the LHW program was never meant to be the panacea for all ills and the mainstay of rural health care ad-infinitum. The fact that in many provinces, district level health care suffers from neglect and suboptimal care is also reflective of lack of investments in upgrading the crumbling infrastructure and distribution of qualified human resources, and a corrupt system of maladministration and limited accountability.
This has led to a multi-tiered health system in the country with urban and relatively well-off populations being able to access care while many of the rural poor are left at the mercy of poorly qualified or unqualified health workers.

While much needed, the devolution of health services and finances to the provinces through the 18th amendment in 2011, was undertaken in haste and with little preparation. Some provinces, notably the Khyber Pakhtunkhwa and Punjab provinces, took up the challenge of reform and regulation with gusto, others were ill prepared and many national programs including the LHW program, the expanded program for childhood immunizations etc. had significant setbacks before course correction. Overall, the devolution of health to the provinces also offered unprecedented opportunity for provinces to strengthen and develop their own strategies, and Khyber Pakhtunkhwa is a case in point. Despite challenges of insecurity and relatively limited fiscal space, the gains in health and nutrition in the province post-devolution were rapid and sustained. The provincial health department also led with the introduction of the Sehat Sahulat health insurance scheme, which within a few years of its introduction, has brought hitherto inaccessible and expensive curative services to those in greatest need and reduced catastrophic health expenditures.

So, in the wake of the current political imbroglio and economic crisis, what is it that we need to do in the health sector over the next decade? I shall list some key actions that might break the log jam for health and development

1) We must make improved public health and nutrition a development priority and non-partisan agenda. Most sensible countries focus on core actions in primary healthcare and equity by developing resilient programs which cannot be tampered with by any change in political leadership. The LHW program is one such example and notwithstanding the ill-advised name-change, the continuation and further refinement of the Benazir Income Support program is another example.

2) Pakistan spends a paltry 0.8% of its GDP on health (and around 1.5% when we take provincial allocations into account). This is likely the lowest allocation for health in South Asia. Despite fiscal exigencies, we need the political will to release resources and increase allocations for primary and basic rural healthcare. Currently, much of the health budgets of provinces are spent on major urban centers and tertiary hospitals. This imbalance must change.

3) To achieve gains in health and nutrition, we must address the social determinants of health.
Investing in female education, empowerment as well as enhancing sexual and reproductive health and rights is of vital importance, and such initiatives need community buy-in and support. Pakistan’s population growth is both rampant and debilitating. No amount of planning can support the burgeoning needs of a population that will exceed 260 million over the next decade. The growing climate and environmental crises create a perfect storm of ill health, poverty, food insecurity with the increased risk of disasters. Accidents and injuries have emerged as a major cause of premature mortality and disability in Pakistan. This must be addressed through strict legislation and implementation of preventive measures across a range of sectors including transportation, construction, building safety and regulation.

4) Enhance the focus on basic, evidence-informed activities within the health sector

The move to provide universal health coverage with agreed packages of care is an important first step. There is no reason Pakistan should continue to face repeated outbreaks of serious life-threatening illnesses such as HIV, Hepatitis B & C and preventable diseases such as polio, now eradicated from all the countries except Pakistan and Afghanistan. The recently developed Disease Control Priority packages must be implemented in letter and spirit especially as they also cover neglected areas such as non-communicable diseases such as mental health, as well as care of the elderly.

5) Focus on reducing disparities in health care and outcomes

As indicated, the differences related to maternal, newborn health and nutrition indicators between high burden districts and others in Pakistan are manifold and must be reduced. This requires a major national initiative focusing on scaling up care packages and financial support mechanisms targeting highest-burden, neglected parts of the country. This needs both push and pull mechanisms. The expansion and provision of health insurance schemes must be coupled with investments in community engagement and strengthening the health system.

Pakistan needs the will to depoliticize public healthcare and focus on achieving health-related sustainable development goals. The country currently spends a paltry 0.8% of its GDP on health. This is likely the lowest allocation for health in South Asia.

Finally, Pakistan needs to completely overhaul its health information and monitoring systems. Over the years, virtually billions have been invested in developing district level health information systems which have limited oversight and dubious validity. The collection of data can only be meaningful if it is used for planning and course correction. As COVID-19 taught us, without real time information systems and importantly, the ability to act on such information, many of the responses are shots in the dark. The core infrastructure for routine health information systems exists and must be made fit for purpose, as opposed to reliance on periodic household surveys.

So, what is the future of public health in Pakistan? In a nutshell, the famous words of Yogi Berra; “We have seen the enemy … and the enemy is us!”. There is no magic wand that can fix the dysfunction that we see in the health sector in Pakistan. We have the solutions. We need the will to depoliticize public health and focus on achieving health-related sustainable development goals.

The International Monetary Fund will not do this for us, nor will blinkered short-sighted politicians. This will need a civic society movement, perhaps led by the 100 million plus young people, whose very future is at stake.

Zulfiqar Ahmed Bhutta

The writer is the Founding Director, Institute for Global Health and Development. He has spent the better part of almost the last 50 years trying to navigate the health sector in Pakistan; as a trainee, a young pediatrician, an academician based in a leading national institution and a researcher steeped in policy and programs in rural Pakistan.

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