Unbridled privatization of health without strong primary healthcare will lead to a strong mafia group to control health policy

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Health dynamics of Pakistan: Are we heading in right direction?
Unbridled privatization of health without
strong primary healthcare will lead to a
strong mafia group to control health policy
Insurance companies never like the idea of
preventive medicine and free medical treatment

Prof. Dr. Ghulam Asghar Channa

Pakistan is fully committed to provide the Universal Health Coverage to people through building resilient and equitable health systems. Government has given strategic priority to UHC in National Health Vision (2016- 2025), it is working with multiple partners for development of National quality policy for health services (since 2017 -18). Pakistan has become 1st Asian country to sign national surgical anesthesia plan in July 2021. The government has invested in Sehat Sahulat card, with important key reforms for efficient health delivery. Primary health care measurement and improvement initiative was also launched recently. Pakistan has also substantially increased the per capita health expenditure from US $ 36 to U.S $ 43 from year 2014 to 2017.


Prof. Dr. Ghulam Asghar Channa

Sincere efforts of Government for improving mixed health system faces social, economic, and political and cross border challenges. The maternal mortality, infant mortality, under five mortalities, burden of communicable and non-communicable diseases stunting in children and adolescence, low immunization and high fertility provide evidence that Pakistan has to redesign strategies to make resilient health system. The outcome gap widens whenever an ineffective intervention fails to bring any change, and frequent failures lead to worst outcome. Health has the central position in education and the economic development. A child who has stunted growth or is suffering from disease will have lesser learning capability and will be up to 70 % less productive in the labor market as compared to one who has normal mental and physical growth and adequate diet. To win economic race, countries are committing increase in funding with effective utilization for health, with main focus to benefit people who need it the most.1

Continuation of trickle-down economic policies, for the development of interests of richer people, industries, private parties and insurance companies give rise to exclusion of deprived, develop inequality in health and promote pauperization.2

Health is fundamental right, which cannot be marketed as a commodity for competitive marketing to the profitable patients, in profitable disease for profitable treatment at the risk of those who need it at the cost of life. Unbridled Privatization of health, without strong primary health care will make private sector a strong lobby on health policy. The example is, power of private insurance companies in India and USA. In U.S.A, Patient protection and Affordable health care bill was rejected by the Trump administration by strong lobbying, as the richest and robust insurance companies do not like the ideas of preventive medicines and free medical treatment. On August 4, 2021, President common wealth fund, David Blumenthal reported that US health insurance does not provide enough health protection, which compromises American’s health and finances, it forces people to skip care or become burdened with medical debt. In India USAID report, (generally favourable to private health insurance,) acknowledged the problem clearly in 2008: ‘… hospitalization coverage is the basis for almost all health insurance … Generally, health insurance coverage does not correspond well to the primary sources of the burden of disease in India’ (USAID, 2008, p. 1).

Health contingencies push the families in Poverty, due to purchase of treatment of a disease or injury suffered due to discrimination or limitations to health information. Discrimination, forced choices, limitation to health information, depriving the right of a person to full potential of life based on economic, and cultural basis is considered structural violence, a term coined by John Galtung in 1960. It is one way of describing the social arrangement which puts populations in harm’s way. This is structured because it is embedded in the social norm and it is violent because it produces injury. This cause and effect have been further elaborated by Paul Former an anthropologist in his Book Pathologies of Power and human rights. The holy grail of deciphering the molecular basis of disease, and limiting benefit of technology for the few fortunate ones has contributed to the progression but has de socialized the medicine. Fruits of medical advances are to be linked to the human rights with approach of equitable distribution as declared in the universal health, to which Pakistan is signatory.


More than 27 countries in the world have accomplished the excellent health care systems and many other developing countries are on the way to the universal heath by the structural and integrated interventions. paradigm is shifting for integration of resource and addressing primary source of diseases. In sixteen (EMRO) regional countries, family practice and primary health is pragmatic part of the health policies. Lack of enough trained family physicians, inadequately equipped health facilities, poor infrastructure and transport to the health facilities in time are the major impediments in making resilient health systems in Pakistan. The health care access and quality of service index outcomes are scored on a scale of 0 to 100 to measure the resilience of health care facilities. The countries with excellent health care score rank between 90-96.

According to Commonwealth Fund the key performance indicators for the health care system are;

A. Care process, this includes the preventive measures, safety of workers and patients, coordination, engagement of stake holders and patient preferences.

B. Access, Affordability and timeliness, especially in emergency process the outcome of treatment depends upon reaching the health care facility in Golden hours.

C. Administrative efficiency, this is selection for the right priority in procurement of service and equipment and elimination of corruption.

D. Equity, health is made affordable to all who need it that is to spend on health projects which benefit many people with adequate financial security.

E. Outcomes are measured as the decrease in the burden of the diseases, patient satisfaction after the use of health facilities.

Common wealth fund used above-mentioned metrics to rank the health systems of countries. Leaving very advanced and industrialized countries, following are few developing countries meeting the above criteria to rank as follows;

* Thailand (47).
* Malaysia (49),
* Sri Lanka (76),
* Bangladesh (88),
* Iran (93),
* Indonesia (92),

Unfortunately, Pakistan is nowhere in the list of one hundred counties.3

Good Value for money matters

Collection, pooling and effective utilization are the basic prerequisite of the funds, health financing no doubt is complex and difficult to understand without truthful data from the country. Allocation of budget for health and its effective utilization by governments is the best indicator of sincerity of a country to health issues. Bangladesh by spending 2.34% of its GDP (Per capita expenditure is US$ 42), stands at number 88th in world ranking. Indonesia spent 2.87 of its GDP in 2018 though not very good but it is at number 90th in ranking. Pakistan spends U.S $43 per capita per year and 3.2 % of GNP and signing multiple MOUs and writing health policies is without any ranking.

Methodology also matters

Bangladesh inherited health system from Pakistan in 1970, still it is has some strengths and many weaknesses like absenteeism, corruption, poor training, gender discrimination and other social issues. Overcoming these hurdles Like many other countries Bangladesh has achieved 100% immunization, brought decrease in fertility rate to 1.3 % in 2010, improved other health parameters and has decreased the burden of the diseases.


Research in underperformance of policies and how to address implementation issues was conducted by interviewing the key informants. These included the diversified stakeholders having multisectoral experience in health and its social importance. Customizing context specific innovation for capacity building, improving health information system, rationalizing medical education, involvement of political leadership contributed to policy preparedness and ownership by the stack holders for success in implementation and improving the outcome.4

Pakistan has developed vigorous policies, strategic vision and ambitious health plans with adequate budgetary allocations. All this is possible because of political willingness for the universal health. Issues to be addressed are underperformance in implementation which can be addressed by:

  • Involvement of the key stack holders at implementation level of policy and addressing their concerns. Investing on development of infrastructure in health facilities.
  • Networking among all the tiers of health delivery systems.
  • Integration of resources, linking medical education with health challenges, to understand and address the biosocial mechanism of disease.
  • Monitoring and continuing medical education and training of health workers.

References

  1. https://www.researchgate.net/publication/5246037_The_Health_Care_Systems_Of_China_And_India_Performance_And_Future_Challenges.
  2. https://en.wikipedia.org/wiki/Trickle-down_economics#cite_note-bloomberg-3.
  3. https://worldpopulationreview.com/country-rankings/best-healthcare-in-the-world.
  4. Taufique Joarder, Tahrim Z. Chaudhury, and Ishtiaq Mannan, Universal Health Coverage in Bangladesh: Activities, Challenges, and Suggestions; Hindawi Advances in Public Health Volume 2019, Article ID 4954095, 12 pages https://doi.org/10.1155/2019/4954095

*Prof. Dr. Ghulam Asghar Channa
Former Vice Chancellor
SMBBMU, Larkana.

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