Health in Pakistan

Pakistan as a developing country is struggling in many fields in which the health system has suffered a lot, resulting in a 122 rank out of 190 countries in a World Health Organization performance report.^[1] Pakistan per capita income (PPP current international $, 2013) is 5,041^[2] and the total expenditure on health per capita (intl $, 2014) is 129, which is only 2.6% of GDP (2014).^[3] The gender inequality in Pakistan is 0.536 and ranks the country 147 out of 188 countries (2004).^[4] The total adult literacy rate in Pakistan is 55% (2014) and primary school enrolment is 73%.^[5] Life expectancy at birth is 66 years (Male 65, female 67),^[6] which is the lowest in comparison to south Asian countries.^[7] The proportion of population which has access to improved drinking water and sanitation is 91% (2015) and 64% (15) respectively.^[6]

Health infrastructure

The health care delivery system includes both state and non-state; and profit and not for profit service provision. The provincial and district health departments, para-statal organizations, social security institutions, non-governmental organizations (NGOs) and private sector finance and provide services mostly through vertically managed disease-specific mechanisms. The country’s health sector is also marked by urban-rural disparities in healthcare delivery and an imbalance in the health workforce, with insufficient health managers, nurses, paramedics and skilled birth attendants in the peripheral areas.^[8]

Health status

Communicable diseases

Communicable diseases have always been the prime cause of mortalities in Pakistan. The reason for the rapid spread of these diseases include overcrowded cities, unsafe drinking water, inadequate sanitation, poor socioeconomic conditions, low health awareness and inadequate vaccination coverage. The epidemic of these diseases is also observed during conflict.

Pakistan is one out of two countries where polio endemic exists (10) and the prevalence of tuberculosis (270 per 100000), malaria and HIV is 12.8 per 1000 and 0.2 per 1000^[9]

• Acute respiratory infection (51%): Among the victims of ARI, most vulnerable are children whose immune systems have been weakened by malnutrition. In 1990, National ARI Control Programme was started in order to reduce the mortality concerned with pneumonia and other respiratory diseases. In following three years, death rates among victims under age of five in Islamabad had been reduced to half.^[10] In 2006, there were 16,056,000 reported cases of ARI, out of which 25.6% were children under age of five.
• Viral hepatitis (7.5%): Viral Hepatitis, particularly that caused by types B and C are major epidemics in Pakistan with nearly 12 million individuals infected with either of the virus. The main cause remains massive overuse of therapeutic injections and reuse of syringes during these injections in the private sector healthcare.
• Malaria (16%): It is a problem faced by the lower-class people in Pakistan. The unsanitary conditions and stagnant water bodies in the rural areas and city slums provide excellent breeding grounds for mosquitoes. Use of nets and mosquito repellents is becoming more common. A programme initiated by the government aims to bring down malarial incidence below 0.01% by the year 2011. In Pakistan, malarial incidence reaches its peak in September. 1000 million people have died from Malaria since Pakistan came into being till December 2012.^[11] In 2006, there were around 4,390,000 new reported cases of fever.
• Diarrhea (15%): There were around 4,500,000 reported cases in 2006, 14% of which were children under the age of five.
• Dysentery (8%) and Scabies (7%)
• Others: goitre, hepatitis and tuberculosis

Infectious diseases in Pakistan by proportion (2006)

Noncommunicable diseases

Non-communicable diseases such as cardiovascular problems, diabetes, cancer and coronary heart disease share 20.5% the burden of diseases and 2.5% are disabled. Pakistan has a high prevalence of blindness, with nearly 1% by WHO criteria for visual impairment – mainly due to cataract. Disability from blindness profoundly affects poverty, education and overall quality of life.^[12]

Controllable diseases

• Cholera: As of 2006, there were a total of 4,610 cases of suspected cholera. However, the floods of 2010 suggested that cholera transmission may be more prevalent than previously understood. Furthermore, research from the Aga Khan University suggests that cholera may account for a quarter of all childhood diarrhea in some parts of rural Sindh.
• Dengue fever: An outbreak of dengue fever occurred in October 2006 in Pakistan. Several deaths occurred due to misdiagnosis, late treatment and lack of awareness in the local population. But overall, steps were taken to kill vectors for the fever and the disease was controlled later, with minimal casualties.
• Measles: As of 2008, there were a total of 441 reported cases of measles in Pakistan.
• Meningococcal meningitis: As of 2006, there were a total of 724 suspected cases of Meningococcal meningitis.

Poliomyelitis

Pakistan is one of the few countries in which poliomyelitis has not been eradicated. As of 2008, there were a total of 89 reported cases of polio in Pakistan.^[13] Polio cases may be on an increase. The year 2010 saw an increase in the number of cases as well as identification of polio from new locations. Experts from the national program and the WHO felt that the new cases identified from southern Punjab and northern Sindh may have resulted from importation of infections from other locations in Pakistan. Locations in FATA and Khyber Pakhtunkhwa remain hosts for year-round persistence of infection and environmental sampling by the national program, and WHO suggests that polio remains endemic in many other parts of the country.

HIV/AIDS

The AIDS epidemic is well established and may even be expanding in Pakistan. Risk factors are high rates of commercial sex and non-marital sex,^[14][15] high levels of therapeutic injections (often with non-sterile equipment),^[16][17] and low use of condoms ^[18] The former National AIDS Control Programme (it was devolved with the Health Ministry) and the UNAIDS state that there are an estimated 97,000 HIV positive individuals in Pakistan. However, these figures are based on dated opinions and inaccurate assumptions; and are inconsistent with available national surveillance data which suggest that the overall number may closer to 40,000.^[19]

Family planning

"The government of Pakistan wants to stabilize the population (achieve zero growth rate) by 2020. And maximizing the usage of family planning methods is one of the pillars of the population program".^[20] The latest Pakistan Demographic and Health Survey (PDHS) conducted by Macro International with partnership of National Institute of Population Studies (NIPS) registered family planning usage in Pakistan to be 30 percent. While this shows an overall increase from 12 percent in 1990-91 (PDHS 1990-91), 8% of these are users of traditional methods.^[21]

Approximately 7 million women use any form of family planning and the number of urban family planning users have remained nearly static between 1990 and 2007. Since a many of contraception users are sterilized (38%), the actual number of women accessing any family planning services in a given year are closer to 3 million with over half buying either condoms or pills from stores directly. Government programs by either the Health or Population ministries together combine to reach less than 1 million users annually.^[21] Thus, fertility remains high, at 4.1 births per woman. Owing to such high fertility levels, Pakistan's overall population growth rate is much higher than elsewhere in South Asia (1.9 percent per year).

Some of the main factors that account for this lack of progress with Family Planning include inadequate programs that don't meet the needs of women who desire family planning or counsel users of family planning about potential side effects, a lack of effective campaign to convince women and their families about the value of smaller families and the overall social mores of a society where women seldom control decisions about their own fertility or families. The single most important factor that has confounded efforts to promote family planning in Pakistan is the lack of consistent supply of commodities and services.^[22]

The unmet need for contraception has remained high at around 25% of all married women of reproductive age (higher than the proportion that are using a modern contraceptive and twice as high as the number of women being served with family planning services in any given year^[23]) and historically any attempt to supply commodities has been met with extremely rapid rise (over 10% per annum) in contraception users compared with the 0.5% increase in national CPR over the past 50 years.

Currently the government contributes about a third of all FP services and the private sector including NGOs the rest. Within the private sector, franchised clinics offer higher quality health care than unfranchised clinics but there is no discernible difference between costs per client and proportion of poorest clients across franchised and unfranchised private clinics.^[24] Government programs are run by both the Ministries of Population Welfare and Health. The most common method used is female sterilization which accounts for over a third of all modern method users. Unfortunately this happens too late for most women as sterilized women are over 30 years of age and have 4 or more children. Condoms are the next most popular method.

Maternal and child health

The health system in Pakistan is influenced by several factors; communicable, non-communicable diseases, malnutrition in children and women and maternal and child morbidities. Pakistan ranks on no 22 in under 5 mortality rate accounting for 81 U5M (2015) per 1000 live births, whereas infant and neonatal mortalities per 1000 live births were 66 and 46. Maternal mortality ratio is also high at 178 per 100000 live births (2015) and only 52% births were attended by skilled worker.^[25]

There is a huge imbalance in these figures. In Balochistan, for instance, the maternal mortality is 785 deaths per 100,000 live births which is nearly triple the national rate. It should be noted here that in rural Pakistan, maternal mortality is nearly twice than that in cities. The sad reality is that 80 per cent of maternal deaths are preventable.^[26]

Nutrition

Nutritionally deprived children not only faces the difficulties in learning but also are at the prime risk of infections, and faces difficulty in combating and recovering from diseases. Whereas extreme nutritional deficiency in can have devastative effect on children such as stunting (45%), wasting (10.5%) and weight gain (4.8%).^[25]

Obesity

Obesity is a health issue that has attracted concern only in the past few years. Urbanisation and an unhealthy, energy-dense diet (the high presence of oil and fats in Pakistani cooking), as well as changing lifestyles, are among the root causes contributing to obesity in the country. According to a list of the world's "fattest countries" published on Forbes, Pakistan is ranked 165 (out of 194 countries) in terms of its overweight population, with 22.2% of individuals over the age of 15 crossing the threshold of obesity.^[27] This ratio roughly corresponds with other studies, which state one-in-four Pakistani adults as being overweight.^[28][29]

Research indicates that people living in large cities in Pakistan are more exposed to the risks of obesity as compared to those in the rural countryside. Women also naturally have higher rates of obesity as compared to men. Pakistan also has the highest percentage of people with diabetes in South Asia.^[30]

According to one study, "fat" is more dangerous for South Asians than for Caucasians because the fat tends to cling to organs like the liver instead of the skin.^[31]

References