Rethinking health and nutrition

Pakistan is a developing country with less than satisfactory performance on internationally accredited health performance indicators. This is not only about the chronic low spending in public health but also about the resources what have never been appropriated to address the key health issues faced by poor people in Pakistan. The supply-driven health policy falls short of addressing the emerging health issues, and health planning is not informed by the social demand.

The country has been ranked far below on the accepted health standards worldwide. Excessive population growth, scarce resources, unclear strategic direction, disconnect between health policy, service delivery and local demands are some of the key factors of Pakistan’s poor performance on most of the health indicators.

The Child Mortality Rate is 86 per 1000 live births; the majority of these deaths are perfectly preventable. Other contributing factors to the dismal condition of health in Pakistan are gender inequities, cultural factors, social constraints on women, terrorism, natural disasters, resistance to vaccines and economic problems. Taking the current situation into account, Pakistan will most likely be unable to achieve its Sustainable Development Goals (SDGs).

Health-based studies in Pakistan indicate low use of government health facilities due to absenteeism, poor quality of service, lack of medicine and unreliable diagnostic practices. This gap has been filled by the private sector; 70 percent of the population in Pakistan seeks private healthcare, despite the financial burden. Public health is also poorly funded for the time being – less than 2/5 percent of GDP, despite excessive population growth.

The highest causes of infant mortality – diarrhea and pneumonia – are perfectly preventable. Other causes are pockets of population that are not immunized for diseases such as measles. Malnutrition in mothers and breast-fed infants is also very high at 43.7 percent, which is one of the highest in South Asian region.

There is a growing realization that, at times, there has been a disconnect between demand articulated at the local level by the communities themselves and service delivery programmes which has resulted in low efficacy of health interventions in general. Even the need-based healthcare programme find it challenging to sustain their effectiveness with the exit of donor-funded projects, particularly in poverty-stricken areas. The private health services that cater to 70 percent patients in Pakistan are not affordable for the poor people whose health spending or inability to pay for basic health perpetuates their poverty.

Another dimension is lack of awareness about preventative measures to reduce the risk of diseases and this lack of awareness is one of the key factors of poor health conditions in Pakistan. The major cause of death in poor areas is perfectly preventable diseases, like diarrhea, malaria, pneumonia and water-born diseases.

Nutrition is another important aspect which has been ignored in the mainstream health policy of the country. It is vital that the national and provincial health policies must focus on nutrition too as a distinct component in their health programme. Creation of awareness regarding malnutrition, balance diet, food security, breast feeding, menstrual hygiene and anemia during pregnancy and in young girls must be an integral part of the behavior change awareness programme of the national health policy. The local units for health services must launch awareness campaign about non-nutritious activities like hand washing, safe drinking water and Open Defecation Free concepts that have a direct bearing on health.

All health and nutrition initiatives must be linked with the broad menu of national and provincial programmes for poverty alleviation to complement the institutional goals of socioeconomic transformation at the local level under SDG commitments. The sustainability of health and nutrition programmes must be predicated upon an integrated development agenda that offers improved access through infrastructure, clean water, income generation and enterprise development for socioeconomic transformation and that promise improved quality of life for the poor.

All poverty alleviation programmes and rural development initiatives like the PPAF and RSPs must capitalize on their main forte, the ability to convene government, private sector, development agencies and their nationwide network of community institutions to address the major challenges of health and nutrition.

Through their vast compendium of institutional network, multi-sector resource-backed capacity and practical experience of health program these development agencies are well positioned to help evolve an institutional accountability mechanism, bridge the gap between demand and supply by linking both streams and testing and scaling up innovation, and sustainable models that ensure access of the poor to quality health services. Following are some of the concrete steps which must be taken to address the health and nutrition issues of the country on a priority basis.

One, revisit the conventional supply driven healthcare practices by linking curative and preventative dimensions of healthcare through local initiatives. This also involves broadening the possibilities for local entrepreneurs to contribute towards provision of cost-effective services to improve accessibility of the poor to healthcare.

Two, devise a range of need-based interventions designed around the human life cycle approach, and pilot innovative models and scale these up through a sector development approach to health.

Third, harness, develop, promote and capacitate local human capital and community institutions in that they are able to articulate their health and nutritional demands, assess the gap in supply and demand and have adequate capacity and wherewithal to connect with the larger eco-system. And, finally, identify the nutritional deficiencies among the poor communities through health action plans and address them through locally informed planning and project designs.

When we talk about sustainable local health and nutrition services we must take advantage of the time-tested and successful models of health and nutrition initiative implemented elsewhere in the world. The most effective model has been the local service delivery as a social enterprise. Social enterprises have been gaining popularity throughout Asia, especially India as successful models of sustainability. Social enterprises could potentially take over projects in place in the future and run them cost effectively – making them accessible to poor on much less cost than they currently pay for unregulated private sector health services.

There are promising examples from across the border, in India, in terms of health-based social enterprises that need to be looked into. For instance, Ziqita as an emergency ambulance operator was set up in 2005 to bring affordable healthcare to some of India’s poorest people. It’s a cross subsidized model that has helped millions of people get to the hospital.

Another economically viable option is the model appropriated by Asian Healthcare Alliance – keeping costs extremely low. AHA is a low-cost provider of diagnostic services in the state of Karnataka (India). Bromley Healthcare in the UK is yet another example of a social enterprise in health services. They provide complimentary care to go with the public healthcare offered by the state.

Finally, an innovative example exists in Florida. PARC (Providing Advocacy and Recognizing Capabilities) is an organization that has transformed itself into a social enterprise.

In Pakistan, Heartfile – which primarily deals with tertiary health – and WHH which provides nutrition support to local organizations are few examples of potential agencies which can introduce technology and innovation to deal with health and nutrition emergency in the country.

The writer is a social development and policy adviser, and a freelance columnist based in Islamabad.

Email: ahnihal@yahoo.com

Twitter: @AmirHussain76