Reimagining healthcare

How will Covid-19 transform health and development in Pakistan?

The Covid-19 pandemic has created unprecedented disruption for health and development in Pakistan. The country’s public health system was overburdened long before the onset of the coronavirus pandemic. Pakistan ranks 154 among 195 countries in terms of quality and accessibility of healthcare. In 2013, only about 52.5 percent of births were attended by skilled heath staff in Pakistan, placing it even behind most African countries, many of whom like Ghana and Congo have similar or lower per capita income. Moreover, in early 2019, in the face of a monetary crisis, Pakistan reached out to the International Monetary Fund (IMF) for a bailout package worth six billion dollars. The economy was only just recovering from the crisis when the pandemic struck. The short-term implications of this global challenge are evident, but the long-term consequences of the pandemic — how it will reshape health and development in Pakistan— are still difficult to imagine.

One can perhaps draw lessons from history to shed light on the medim to longer-term effects of Covid-19. In a recent work, Harvard economist, Robert Barro, and colleagues estimated the effect of the Spanish flu-related deaths in 43 countries in 1918-1920, and concluded that higher flu death rates led to declines in GDP and consumption of about 6 percent (using data between 1901 and 1929). The Indian subcontinent (including what is now Pakistan) saw the second highest cumulative mortality rate of 5.2 percent in the world, leading to 42 percent of all deaths from the Indian subcontinent. Their model implies a contraction in Indian real per capita GDP by a staggering 15 percent. In fact, the death and economic toll of the pandemics under British-controlled India fuelled fire into the existing Independence movements leading to the creation of Pakistan decades later.

Perhaps one of the most enduring effects of Covid-19 may not be on adults today but on children who are not even born.

Perhaps one of the most enduring effects of Covid-19 may not be on adults today but on children who are not even born. In 2012, there were approximately nine million pregnancies in Pakistan, of which 4.2 million were unintended. As a UN report warns Covid-19 could lead to millions of additional unintended pregnancies due to lack of family planning and reduced access to contraceptives. In addition to excess fertility and its ensuing challenges, an important long-term challenge is expected to come from the entire cohorts of (intended or unintended) pregnancies over the length of Covid-19, especially among poor families in Pakistan. These children will be born in a time of reduced economic resources, worse public health and misinformation that is differentially affecting women, who usually assume the burden of care in Pakistani families. As compared to 21 percent male respondents, 32 percent of women interviewed for a recent UN survey in Pakistan reported having never received any official information on Covid-19. Only 51 percent of Pakistani women said they had received clear and helpful information from any source, which is significantly lower than regional peers like Nepal (63 percent), Maldives (83 percent) and Cambodia (71 percent). Moreover, 52 percent of Pakistani women were unable to seek medical care when needed and 66 percent of women reported that their mental health was affected by Covid-19. Maternity wards have been reported closed. As mothers have worse mental health and are even less able to access healthcare, and as misinformation abounds, one can expect these factors to have catastrophic effects on the fetal and early childhood environment.

Economists have studied the long-term effects of the 1918 Spanish Influenza as a case study (“natural experiment”) to test the fetal origins hypothesis. The fetal origins hypothesis predicts that individual health as well as socioeconomic outcomes later in life are affected by the health of that individual while in utero. Studies have found that the 1918 influenza led to reduced educational attainment, increased rates of disability, lower income and lower socioeconomic status in the US. Similar effects have been found in Brazil, Britain, Switzerland and Taiwan.

The concern then is that Covid-19 may not just end in a year or two, but its effects may be witnessed for several decades into the future.

One of the silver linings from the current pandemic is a greater degree of experimentation and acceptance of telemedicine. If this trend continues, Pakistan could leverage the power of telemedicine services to offer gender-sensitive technology-enabled trainings to its community health workers. Community health workers in turn could help offer low cost maternal and child health counselling to marginalised mothers and young women. Furthermore, teleconsultations by skilled doctors to marginalised women along with referrals to appropriate tertiary care services could help optimise continuity of care along the entire healthcare system of Pakistan. This in turn can help Pakistan be better prepared for the next healthcare and concomitant economic crises.

The writer is a global health economist who is currently an assistant professor at the  Department of Economics at the University of  Georgia, USA

Reimagining healthcare: How will Covid-19 transform health and development in Pakistan?