HR Ahmad*
The first NHP – the national health policy was designed by Dr Tariq Sohail as health advisor of then prime minister Benazir Bhutto. His NHP narratives in the form of an oral history have lucidly been described in Hakayet e Dil Dard Ashna, IHSR 2025.
HR Ahmad
The first challenge in implementation of NHP is how to generate consensus among the stakeholders such as nurses, paramedics, doctors and owners of private hospitals and their health providing teams. It is because majority of health-related activities occur in provinces. Thus, the NHP implementation can occur through the consensus of health workers and their respective associations in each province to finally loop with the ministry of health.
Of note is the fact, one should be able to differentiate between public and private health care. Public health care deals the communicable diseases of a population. It includes clean water, nutrition, pregnancy, mother and child care. Private health care deals with diseases as one to one operation between a physician and a patient. The next challenge is how are drugs managed and distributed. Drugs are supplied by all means of transportation available to reach each corner of a village and a city.
Now the question to be raised as to what are steps in forming health policy per narrative of Tariq Sohail:
- Consolidating intention,
- Roadmap outlining,
- Exchange of notes on different proposals,
- Integration of overlapping areas,
- Dignity conserving care,
- Roles of doctors. They think they can do everything but in public health practice, it is not evidenced because of the demand of a diversified team work. Furthermore, the government budget of the public health care is 20 times less than private one.
Interesting encounter of Tariq Sohail with Turner, a professor of cardiology from Edinburgh in Karachi in 1981-1982. He inquired if there were public health units in Pakistan while regretting spending heavily on institutions of cardiovascular diseases and emphasis on hospitals building at the cost of PHUs. Tariq Sohail asked Turner what could be the relationship of cardiac diseases with the environment? Turner replied if you plot the incidence of cardiac diseases against the number of cars as a function of time in years e.g. 1920 – 1970, you will find an exponential increase in cardiac disease with increasing number of cars on the road. It means the lifestyle of walking is replaced by cars meaning end of exercise of Homo sapiens with all consequences. It is a matter of great concern that there is no public health facilities but hospitals are built at a higher rate as a glory for politicians and rulers.
Now the question arises how the clean water bill and infant nutrition bill did not see the light of the day in the parliament debate. The history shows that the first clean water bill was passed by British parliament and implemented in 1948. Its impact significantly reduced the communicable diseases in UK, Europe and USA. It showed that even it edged over the vaccination strategy. However, the case is reversed in Pakistan with emphasis on vaccination. However clean water is then supplied to hospitals. It is tested for impurity, reversed osmosis and then tested as a quality control at intervals. How is clean water supplied to common people? This remains an issue not yet resolved due to admixing with open sewerage on the road.
The yearly survey from the Finance Department announced the new health policy to be introduced in the year 1991 – 1992. The policy would cover the following:
- To provide the primary health care by the year 2000.
- To control treatable diseases being cost effective,
- To provide clean water and drainage of water. PHC includes immunization, population control, clean water and drainage system. This health policy was well funded by WHO, WB, UNICEF and USAID despite the absence clean water bill being approved by the parliament.
However, one of the successful outcomes of PHC was the growth of forty thousand lady health visitor strategy especially in village than urban settings. However, the policy did not continue due to change in the government ruling team after the prime ministership of Benazir Bhutto.
Of note is the fact that the budget of public health care is far less than that of private health care. It is evidenced by mushrooming of more hospitals than basic health units to attract votes for the parliament seats. In 1989, with reference to the ministry of health, there were 52,000 registered doctors, 2100 dentists, 17,000 nurses, 2 – 4 beds per nurse, one hospital per 1500 population, one doctor per 2000 population, one dentist per 53,000 population. However, recent 2021 survey of Pakistan Bureau of Statistics shows 27,000 doctors, 31,000 dentists, 121,000 nurses, 45,000 delivery assistants, and 22,000 lady health visitors were registered. WHO prescribes one doctor per 1000 population. However, it is difficult to sustain and improve health indices and human development index as thousands of doctors leave the country for further training of expertise. Mother state has no budget to hold them back to serve the country. Partly, it seems to be buffered by mushrooming of private medical colleges from 1983 onwards. Thus, there is continuous brain and capital drain from the country to establish a balance between public and private health care.
The first dental college was a part of Fatima Jinnah Medical College. Following this model, many medical colleges were privately established after 1983. However, qualified dentists could not be fully absorbed due to lack of work space in the government sectors. This gap couldn’t be bridged as the opening of private dental clinics were rather expensive. There is yet no space for dental care even part time through thousands of Basic Health Units and hundreds of Rural Health Centers.
The performance of BHUs depends on the provincial art of governance. It is reported that in Peshawar, BHUs worked well as a patient was treated within a cost of Rs 80 in 1990. Good patient attendance is a useful marker for functioning of BHUs as the basic cost remains the same for all units. Good governance can resolve this issue.
In 1990, the status of nutrition per person was 2400 kcal. It increased to 3000 kcal. It has not reached the target because children’s nutrition was rather deficient especially proteins being essential for brain development. The cost of food per basket had been increased since 2022. It included cereal, carbohydrates and proteins. Since nutrition is an essential part of health, many diseases can be due to their deprivation. Tuberculosis is one of diseases of poverty.
Health indicators showed rather high infant and maternal mortality. In 1998, infant mortality was 170 per thousand children’s live births and maternal mortality corresponded to 500 per 100,000 pregnancies. It dropped to 190 and infant mortality to 50 per live births in 2022. Factors contributing to this improvement in health indices were trained staff, lady health visitors and vaccination. Death rate, life expectancy and fertility rate tended to improve. However, polio, tuberculosis, drug addiction and population control are not control able under the regimen of PHC, RHU and BHUs.
Drug Addiction. One of the major issues was to face how to combat the onset of drug addiction by the ministry of health. There were three million addicts according to 1989 survey. Of note is the fact, a joint anti-narcotics force was established by USA and Pakistan governments. It aimed to prevent the drug addiction from spreading in a population. Earlier opium was freely available in shops being consumed by children and senior citizens as medicine. However, on a proposal from USA, the selling of opium was declared as an act of crime. Consequently, all opium selling shops were closed. But with the passage of time, the opium trade went underground. It was taken over by non-state actors — mafia groups. Instead of being checked by ANF, the opium business explored further with a new product on sale namely heroin. Its demand attracted beyond the national borders. The survey showed 340 million addicts to be hooked by this drug. Interestingly, it reduced the alcohol consumption as being replaced by the heroin intake.
However, all sorts of addict-able drugs were available in the tablet form despite being unlawful. Contrastingly, opium and heroin were lawfully available in the world including USA. Hardworking professionals like truck drivers and wall painters used to take these drugs as a source of relaxation. Additionally, these drugs were prescribed by for diarrhea, cancer, and arthritis by physicians. However, ANF is controlling the drug addicts by referring them to rehabilitation centers.
Originally, the population control was a part of the national health policy. The population was 110 million in 1989, 150 million in 2000 and 250 million in 2025. Consequently, the uncontrollable increase in population has off set the balance sheet of supply and demand of resources. Bangladesh and Indonesia were able to control but Pakistan failed in it due to being partly not belonging to the ministry of health as further elucidated by Zaki Hasan in Public Health Challenges in Pakistan 2006.
COVID – 19 started to infect population from January 2020 to 2022. Government worked by introducing a strategy of smart lock down but not uniformly complete. However, this enabled the service and education to be functioning on line without human contact. The vaccination programs were well funded and executed by both national and international resources. Survey showed cities to be more infected than villages because of less open spaces between homes. Yet a part of the population acquired herd immunity to have remained protected from COVID – 19.
Dedicated to the fond memories of a scientist cardiologist CW Vellani in September, a scientist neurologist Nadir Ali Syed in August, and the Chancellor of Aga Khan University in February 2025.
*Author HR Ahmad can be reached at hrahmad.alrazi@gmail.com
Rochester MN 6 September 2025.
