S.N.B. Inam ( Department of Community Health Sciences Ziauddin Medical University. Karachi. )
S. Safdar ( Department of Community Health Sciences Ziauddin Medical University. Karachi. )
A. Omair ( Department of Community Health Sciences Ziauddin Medical University. Karachi. )
National Health Status
While entering into the new millennium, Pakistan needs to assess its position on the health status of its nation. The health of its 130 million citizens is among the poorest in the world and its number is growing at the rate of 2.6% per annum1. At this rate the population will double by the year 2027. Is the country prepared for such a challenging burden?
Forty percent of children under-five-years of age are malnourished. Twenty-nine percent of population lives in poverty and 12% is surviving on less than Idollar a day2. Lack of proper access to water and sanitation1 translates into high incidence of infectious disease, which take its toll on its children. One out of every tenth child born, does not live to see his/her first birthday. Twenty-five percent of all children born are of low birth weight, i.e., less than 2.5 kg. These children are usually born to mothers who are malnourished. Almost 50% women of childbearning age suffer from nutritional anemia2. In contrast to Western women, all Pakistani women are at increased risk of dying due to pregnancy related causes. Maternal mortality rate in Pakistan is estimated to be between 340 and 600 per hundred thousand live births3,4. This means that one pregnant woman dies eveiy twenty minutes, due mostly to avoidable causes.
Illiteracy has also contributed toward the poor state of health. The average years of education for men and women are 2.9 and 0.7 respectively. Sixty-one percent of population cannot read or write. The situation with women is even worse(72%). A cross national study revealed that one to three years of mother’s schooling is associated with a 20% decline in risk of childhood mortality5. By doubling secondary school enrollment the infant mortality rate can be decreased by 64%6.
In Pakistan, it is estimated that a $40,000 investment in educating 1000 women would avert 660 births and save over $250,000 needed to sustain the new babies at the level of average per capita income6. In Bangladesh, the contraceptive prevalence rate increased from 27% among women with no education to 36% among women with more than secondary level education7. In Pakistan poverty coupled with illiteracy and rapid population growth has amplified the magnitude of health problems it faces in the 21st century.
While the health system of the country has yet to evolve an effective and efficient system for tackling the infectious disease burden, the diseases of lifestyle also call for a more serious galvanizing of the system to appropriately address their challenge. Old age, sedentary lifestyle and obesity are associated with high prevalence of hypertension (17.9%), diabetes (10%) and hypercholestremia (3.7%) which are precursors of chronic disease8. This double burden of disease has put pressure on the shrinking resources of the country and calls for readjustment and realignment of national priorities, which unfortunately have been neglected in the past. An example of misplaced priorities can no better be demonstrated by the fact that together India and Pakistan spend over $12 billion per year on defence. If defence expenditure are cut by 5% per year over the next five years it could release about $22 billion which is four times the amount required for the goal of universal primary education within the next five years 6. The country cannot reach its potential if the education and health of its population is neglected. Poor health contributes to reduced productivity. In 1990 alone, the worldwide loss of social productivity caused by four overlapping types of malnutrition - nutritional stunting and wasting, iodine deficiency and deficiencies of iron and vitamin A, amounted to almost 46 million years of productive disability-free life9.
The Challenge for Academia
Traditionally, universities are considered seats of learning and research. But with particular reference to teaching medical institutions in Pakistan, the situation is quite dismal. The universities should ensure that they have agenda that is congruent with the national needs and realities. The questions that should be answered by any medical insititution are, whether they are poised to face the challenge of the national health system? Are their human resource development policies in line with the health systems requirement ? How much evidence-based input does our academia impart to the policy makers and program implementers? Is the curriculum geared towards the needs of today and the challenges of tomorrow? Is the training of medical students and other health personnel aimed to suit the needs of the system? How much emphasis is being placed on research? What is the direction of research?
These are some cardinal questions for our academia to take up and work through, in order to exert its due influence on the health status of the nation. The answer may not be easy. The route to be taken certainly is not smooth. But nevertheless the willingness to commit to the social responsibility is the first step in realigning the focus and becoming a part of the changing global trends in medical education and health systems reform.
All medical universities/colleges should commit to modify their curriculum to meet the challenge of tomorrow. They should institute for sharing and pooling scarce resources; collaborate with NGOs outside universities and develop mutually beneficial relationship. They should work towards:
Promoting inter-sectoral action for health at the local, regional and national levels by working with sectors such as education, business, agriculture and transport to develop and implement effective policies.
• Identifying effective interventions based on evidence to reduce inequalities in health. Facilitating exchange of khowledge and effective ways of working.
• Ensuring that education programs for health professionals include appropriate information on the impact of socioeconomic inequalities on health and what health professionals can do to reduce such inequalities.
• Encouraging health professionals to work with local communities to improve the health of the poorest.
Monitoring trends in health inequalities and using data to influence policy.
A partnership between academia, government and relevant non-governmental organization is required. Terms of reference for this partnership should be clear. The agenda has to be national and not dictated by donor agencies. The first and most essential step in moving towards the right direction is political commitment at the highest level and to ensure sustainability of political commitment.
Some of the measures required immediately are:
formation of bodies in every medical university/college with the task of defining their mission with special reference to addressing and development needs of the nation; instituting committees at national levels with representatives from policy making and program implementing bodies of the government and universities to identify competency requirements, human resources of different types and levels in health; provide guidelines for modifying the curriculum and training to health systems new the private and public sector; identify mechanisms for inter-sectoral collaboration; outline the essential national health research agenda that need to be addressed by the universities and defining the modus operandi for action.
Health is not an isolated phenomenon and the responsibility for its improvement and maintenance cuts across disciplines. The gravity of the problems of poverty and under-development makes it imperative, that policy makers and planners along with health professionals, need to understand the intricate relationship of social determinants of health and development from a fresh perspective of human development. The focus and priorities need to be realigned in the light of better understanding of equitable distribution of dividends of economic growth by reducing societal disparities and increasing opportunities for participation in enhancing societal gains. A more integrated, multi-sectoral approach has to be adopted. The challenges need to be addressed with consensus building as an initial step for galvanizing momentum for institutional and political will to redress the ill health of the nation.
1.Government of Pakistan Economic Survey of Pakistan-2000. Islamabad, Ministry of Finance, 2000.
2.UNICEF State of worlds children-2000. Oxford University Press.2000.
3.WHO World Health Report, Geneva, WHO, 1999.
4.MIMS Report of demographic. household and maternal health survey of Sindh, Karachi, Aga Khan University, 1994.
5.World Bank Primary Education in India, Washington D.C, World Bank, 1997.
6.Haq, M, Haq, K. Human development in south-east Asia-1998, Human Development Center, Oxford, U iniversity Press. 1998.
7.World Bank Annual Report-1993. Washingion D.C. Won Bank. 1993.
8.PMRC National Health Survey 990-94. Islamabad, PMRC. 1997.
9.UNICEF State of words children- 1998, Oxford University Press, 1998.