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A lasting national health policy (NHP) has eluded us for the past five decades and most of the time adhocisrn has been the basis of our time adbocism has been the basis of our health planning which has leaked direction and consistency. The pre-partition Bhore Committee Report was followed >;» Pakistan as such and it took us over a decade to realise that the emerging demographic and socioeconomic realities of a new country demanded fresh thinking. Several commissions were set up, each regime giving out a new health policy. Some positive contributions were made by Gen. W. A. Burki (establishment of basic 'icalth units) and Sheikh Rashid (generic drug policy), but al! the policies formulated so far were at best only partially implemented an were short-lived. Innumerable committees, conferences and symposiums were organised, some with the participation are gathering dust on the shelves of the Ministry, along with valuable projections and recommendations made from time to time by the Health Division of the Planning Commission.
The reasons for this state of affairs include political instability, economic constraints, lack of overall national direction, adhocism and rampant corruption. The social sector has been the worst casualty and health has been getting the lowest priority in our development plans. It has, perhaps, never been the intention of the successive governments to provide medical are to the masses, the social action programme and similar other schemes notwithstanding. , '
Some growth in health care has inevitably taken place over the years both ia the public and private sectors. A number of new hospitals, speciality institutes, undergraduate medical colleges and post-graduate ventures have been established, and the District Headquarters Hospitals have been upgraded along with a mushrooming of private clinics/laboratories its big and small towns. However, all this has been unplanned and haphazard. The so-called health delivery system (HDS) has therefore failed to cater even forth minimum requirements of the fast multiplying population. The urban dwellers have to buy health care in the private as well as government hospitals. There is widespread corruption at all levels in454
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the departments of health and the private sector is unregulated and uncontrolled.
Seventy percent of our rural and fifty percent of the urban population does not get safe drinking water, about 90 million are without elementary sanitation facilities and around 60 million lack access to basic health care and are being exploited by quacks.
The ratings for health services in Pakistan, according to an international classification paint a dismal picture: Eighty nine per cent of preventive and promotive services are insufficient or worse, while on the curative side, 892 per cent of primary, 86 per cent of secondary and 77 per cent of territory care is insignificantly poor or insufficient.
The multinational pharmaceutical companies are having a bonanza in Pakistan by selling drugs at 4-5 times the prices being charged by them in India and Bangladesh. Eighty per cent of the total treatment cost of a patient is spent on purchase of drugs. The total sale of rugs in the year 1995 amounted to Rs. 28 billion. The multinational drug companies have a monopoly on sixty per cent of the market. These companies import the raw materials from cheap sources, pack it under their brand names and sell them at huge profits with the connivance and complicity of the concerned authorities. The total number of drugs registered in Pakistan is a staggering figure of 18000 and many of them are substandard, harmful or useless.
According ta the World Bank Book of Social Indicators of Development for the developing countries, Pakistan has half the number of doctors for it present population of 130 million. The shortage of specialists, nurses, dentists and medical technologist is even more acute. Pakistan has the distinction of ranking 108th in the world in human resource development index in general. The situation shall be worse in 2020, when our population is likely to double. The available number of health car personnel is not being properly utilised because of the lack of infra structure in the rural areas. '
The chairs in medical teaching institutions are occupied mostly by part-time incumbents, having divided loyalties between the institutions an their private practice establishment. There is no entry test for admission to medical colleges and the tuition fees are only a token. There is no consensus regarding the type of medical graduate required. The curricula are outdated and the studentteacher ratio in the over-crowded classes is unsatisfactory resulting in a sharp decline in the quality of medical education There are no
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structured training programmes for the teachers. The affiliated hospitals have too many doctors who are poorly paid. There is no arrangement for continuing medical education at any level in the profession.
There is hegemonic bureaucratic control in planning and administration of health care with only marginal technocratic involvement. Medical managers and administrators are not given due recognition, an there are insufficient facilities for training in these specialities.
Prevention of disease and promotion of health are as important as curative health care. But the major focus of our medicare efforts so far has been on the curative side, which is more popular with the medical profession and the public representatives, both of them having vested self-interest in its perpetuation. Extended programmes of immunisation, anti-malaria campaigns, maternal and child health programmes some others have achieved varying degrees of success. But there appears to be little comprehension of the magnitude of the effort needed in this crucial area of the HDS, resulting in unplanned and disorganised activity in this field. There is no national programme of prevention for cardiovascular disorders and cancer affecting millions of people, and only an insignificant anti-smoking warning is flashed at the end of glamorous TV commercials on cigarettes, while the emergence o a couple of thousand cases of AIDS has caught the fancy of our administrators for a national campaign. The hazards of environmental pollution have yet to be fully recognised.
The main factors influencing a person's health are his income, lifestyle, environmental pollution, occupational risks and the quality of available health care. Health care is a basic human requirement to raise life expectancy, reduce the burden of disease and disability, increase productivity and improve the quality of life.
The primary objective of HDS is equitable access to health care to every citizen, especially to the disadvantaged sections of the community. To achieve this goal, a NHP has to be formulated, addressing the basic issues fix exact delineation of the respective roles of public and private enterprise, recognition of the importance of preventive versus curative and primary versus secondary an tertiary care, reforms in the health care teaching institutions, enforcement of accountability and regulatory controls and enhancement of budgetary allocation. All the problems besting the HDS are corollaries of these fundamental issues. 458
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should also be made to introduce the system of continuing medical education and reaccreditation at all levels of the profession. The career structure of doctors in government service should be revised with sufficient incentives to motivate the doctors to become dedicated whole time workers.
The present government is engaged in grappling with a plethora of pressing problems, and medicare is not one of them. But what is more disconcerting is that varying types of fragmented and conflicting signals without any clear-cut direction are emanating from different sources. Three medical colleges are being given autonomy, while self-financing scheme is being abolished. The old experiment of district health authorities is being revived in two district in Punjab and work is in progress on leasing out rural health centres. A scheme to issue health cards is on the anvil and twelve hundred doctors are being appointed on contract jobs. The reportedly lustreless debate on provincial health policy in a recent session of Punjab Assembly by a minimum of quorum reflected the priority given to medicare, and its inputs were the well known of repeated cliches regarding corruption, negligence, non-availability of doctor, paramedics, drugs and ambulances, career structure of doctors, drug price control, encouragement and regulation of private enterprises, etc.
All this does not appear to be part of a prepared comprehensive national/provincial health policy. It is high time that such an exercise is undertaken without further delay. The constitution of the task force/committee required for this purpose is of crucial importance and must include professional experts on health, economy, finance, food and agriculture, information media and environment along with some elected representatives Again, it should not be one time deliberation. There has to be a permanent ,think-tank in the background comprising mainly of technical experts with research fellows assigned to university departments to assist them. It is not novel idea and should in fact form a standard practice in every field of activity, because dynamic programmes can only be made through research and development which is an ongoing process.