The Lancet Series - Health transitions in Pakistan
News 2013
Health in Pakistan at a Turning Point

May 17, 2013

​As the dust settles from recent elections and a new era in state governance begins, The Lancet has published special Series on Health Transitions in Pakistan. In this Series, The Lancet focuses on four priorities for Pakistan’s health system in order to offer ideas for accelerating Pakistan’s development trajectory: first, the country's performance and future after the 18th Amendment to the Constitution in which the federal Ministry of Health was abolished; second, reproductive, maternal, newborn, and child health; third, non-communicable diseases and injuries; and fourth, recommendations for future ​health reforms.

The Series of papers were led by Dr Sania Nishtar, Founder and President of Heartfile, a non-profit health think tank based in Islamabad, Pakistan, and Professor Zulfiqar Bhutta, Founding Director of the Centre of Excellence in Women and Child Health, Aga Khan University, Karachi, Pakistan. The official launch was held in Islamabad and attended by representatives of leading political parties.

Commenting on the opportunities that the current socio-political scenario presents, Professor Bhutta said, “Rarely have the Pakistani people had the luxury to take stock and generate support to address the closely intertwined issues of health, human security, and development. Now is the opportunity to offer options for the future.” 

His paper in the series, Reproductive, Maternal, Newborn, And Child Health In Pakistan: Challenges And Opportunities, co-authored with other experts from AKU and other national institutions focussed on identifying and providing solutions to preventable causes of death.

“The cycle of unfettered population growth and poor health of mothers and their children has impeded Pakistan’s progress in health and development in recent decades, and as a result, we now lag behind many similar countries in the region, even those with fewer resources,” said Professor Bhutta.

Reasons for this poor performance include widespread poverty and poor education; poor coverage of vaccination programmes; and lack of appropriate training for community health workers, despite the successes of Pakistan’s pioneering Lady Health Worker Programme.

If evidence-based actions are undertaken in time, the lives of 200,000 women and children, almost 58% of current deaths can be saved in 2015. For this, Professor Bhutta et al have identified seven key intervention packages – all of which are relatively low cost, and have been proven to work in the region. 

The interventions identified involved providing adequate care to mothers throughout, and after, their pregnancy, comprehensive management of childhood illness, and expanding nutrition and vaccination programmes. Many of these interventions can be specifically targeted to reaching the poor and the estimates show that the bulk of lives saved are those in difficult to reach rural populations and urban poor.

“The crisis of governance and poor political ownership of maternal and child health have played the main part in the lack of progress in women and children’s health in Pakistan because no political parties have thought that this is a political priority,” commented Professor Bhutta.  “For the situation to change, women and children’s health must receive concerted support from all sections of a male-dominated society.”

Meanwhile, Pakistan’s Health System: Performance And Prospects After the 18th Constitutional Amendment, and Health Reform In Pakistan: A Call To Action, the latter co-authored by Dr Sania Nishtar and Prof Bhutta, rated the performance of Pakistan against 12 peer countries on 13 key indicators and suggested solutions for health reforms.

The determinants of health included improved sanitation, life expectancy and attendance of a skilled medical practitioner at birth, and shockingly, Pakistan ranked below average in nearly all the areas studied. In fact, average life expectancy deteriorated between 1990 and 2010 compared to average rates in the other countries.

“A major part of the problem is health financing,” Dr Nishtar explained, “the government spent less than four per cent of its budget in 2009 on health – half of the average for the peer-country group.”

The papers recommend that a federal institutional system to support the provincial departments of health be set up with links to appropriate ministries and divisions, which can provide oversight of national health policy aims. 

In tandem, an increase in investment in health care has been recommended. Government investment in health should increase to at least 5 per cent of GDP by 2025 but even in a constrained fiscal environment, policy makers could get much better value for their health spending by better management of resources.

Finally, the authors said that public health work needs to be carefully integrated with medical care if the health reforms are to be a success.

The fourth paper in the series Non-Communicable Diseases and Injuries in Pakistan: Strategic Priorities by Dr Tazeen Jaffer, former AKU faculty member and currently with Duke-NUS Graduate Medical School, Singapore, assessed the impact of non-communicable diseases.

Speaking about her work, Dr Jaffar said, “If current trends continue, nearly 4 million people aged 30-69 years are predicted to die from cardiovascular disease, cancers, and chronic respiratory disease by 2025.”

“However, implementing the full range of interventions recommended by the authors would cost just US$ 2 per person per year, a miniscule amount compared to the estimated costs of loss of productivity and economy,” she commented.

Also contributing to The Lancet edition with their Comments were former President of AKU Shamsh Kassim-Lakha with Philanthropic Funding for Health in Pakistan, and Dr Shehla Zaidi, Community Health Sciences, AKU, with Medical Education and Research in Pakistan.