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Pakistan: health is an opportunity to be seized
Comment
Pakistan occupies a special place in global health for at least four reasons. First, Pakistan is a phenomenally research productive nation. The country’s imprint in The Lancet, for example, is extraordinary, and extends over many decades—from optimisimg the health of pregnant women,1 to improving case management of pneumonia,2 to identifying the potentially harmful effects of widely used micronutrient powders to prevent nutritional anaemia in children.3 Second, Pakistan’s medical and public health communities have delivered important innovations, such as school-based mentalhealth programmes4 and community-based Lady Health Workers,5 both of which have had important impacts on population health. The introduction of a new cadre of community health worker has had an especially important part to play in reducing stillbirths and newborn mortality, evidence that has had global reach. Third, Pakistan has produced leaders in health who have made a demonstrable difference both domestically and internationally—eg, identifying non-communicable diseases as a threat to the health of people in south Asia,6 signalling the dangers of abolishing Pakistan’s Ministry of Health,7 raising the alarm about substandard medicines,8 and mobilising the Muslim world to defeat polio.9 And finally, Pakistan’s health scientists have been the motive force behind important collaborations, such as Countdown to 2015 and the Partnership for Maternal, Newborn, and Child Health, which have transformed the international community’s response to health predicaments. For these reasons alone, Pakistan demands attention. But now, thanks to the able leadership of Sania Nishtar and her colleagues, especially Zulfiqar Bhutta, we take those reasons one step further by publishing four papers in a Series that examines the remarkable transitions in Pakistan’s health system.10–13 These transitions are important not only for Pakistan’s new Government, but also for a broader international audience that faces many of the same challenges that Pakistan confronts. Pakistan is classed by the annual UN Human Development Report as a “low human development” nation. In 2013, Pakistan was ranked 146 out of 186 countries, according to a Human Development Index that is a composite measure of income, education, and life expectancy.14 In this www.thelancet.com Vol 381 June 22, 2013
Lancet Series, we focus 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.10 Second, reproductive, maternal, newborn, and child health.11 Third, non-communicable diseases and injuries.12 And fourth, recommendations for future health reforms.13 Pakistan’s challenges are considerable. To take one example: nutrition. Almost half of Pakistan’s mothers and children are undernourished. Over 1·5 million children have acute malnutrition. And almost half of mothers are anaemic. The chronic effects of undernutrition are bad enough for health. But they also have a draining effect on the economy, with some estimates suggesting that malnutrition costs Pakistan 3% of its gross domestic product annually. The systematic failure to address nutrition is one that has endured in Pakistan for 40 years. It must be prioritised. In 2002, Pakistan initiated major reforms in its highereducation system. Although not without difficulties, these reforms changed the culture of academia to one that is focused on research, quality, and impact. It is surely time now for Pakistan to turn its attention to the health sector, especially since Pakistan is now the only country in the world without national governance for health. Thanks to Pakistan’s own vibrant professional, research, and civil society communities, solutions are available to politicians and policy makers alike, solutions that could quickly and decisively make a difference to the health of Pakistan’s population.
AP BK Bangash/AP/Press Association Images
Pakistan: health is an opportunity to be seized
Published Online May 17, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)60946-0 See Series pages 2193 and 2207 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(13)60646-7 and http://dx.doi.org/10.1016/ S0140-6736(13)60813-2
Richard Horton The Lancet, London NW1 7BY, UK 1 2
3
4
5
Rab SM, Baseer A. Occult osteomalacia amongst healthy and pregnant women in Pakistan. Lancet 1976; 2: 1211–13. Bari A, Sadruddin S, Khan A, et al. Community case management of severe pneumonia with oral amoxicillin in children aged 2–59 months in Haripur district, Pakistan. Lancet 2011; 378: 1796–803. Soofi S, Cousens S, Iqbal SP, et al. Effect of provision of daily zinc and iron with several micronutrients on growth and morbidity among young children in Pakistan. Lancet 2013; published online April 18. http://dx.doi.org/ 10.1016/S0140-6736(13)60437-7. Rahman A, Mubbashar MH, Gater R, Goldberg D. Randomised trial of impact of school mental-health programme in rural Rawalpindi, Pakistan. Lancet 1998; 352: 1022–25. Bhutta ZA, Soofi S, Cousens S, et al. Improvement of perinatal and newborn care in rural Pakistan through community-based strategies. Lancet 2011; 377: 403–12.
2137
Comment
6
7 8 9
10
Jafa TH, Hatcher J, Poulter N, et al. Community-based interventions to promote blood pressure control in a developing country. Ann Intern Med 2009; 151: 593–601. Nishtar S, Mehboob AB. Pakistan prepares to abolish Ministry of Health. Lancet 2011; 378: 648–49. Nishtar S. Pakistan’s deadly cocktail of substandard drugs. Lancet 2012; 379: 1084–85. Ahmed QA, Nishtar S, Memish ZA. Poliomyelitis in Pakistan: time for the Muslim world to step in. Lancet 2013; published online April 24 http:// dx.doi.org/10.1016/S0140-6736(13)60764-3. Nishtar S, Boerma T, Amjad S, et al. Pakistan’s health system: performance and prospects after the 18th Constitutional Amendment. Lancet 2013; published online May 17. http://dx.doi.org/10.1016/S0140-6736(13)60019-7.
11
12
13
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Bhutta ZA, Hafeez A, Rizvi A, et al. Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities. Lancet 2013; published online May 17. http://dx.doi.org/10.1016/S0140-6736(12)61999-0. Jafar TH, Haaland BA, Rahman A, et al. Non-communicable diseases and injuries in Pakistan: strategic priorities. Lancet 2013; published online May 17. http://dx.doi.org/10.1016/S0140-6736(13)60646-7. Nishtar S, Bhutta ZA, Jafar TH, et al. Health reform in Pakistan: a call to action. Lancet 2013; published online May 17. http://dx.doi.org/10.1016/ S0140-6736(13)60813-2. United Nations Development Programme. Country profiles and international human development indicators. Pakistan. 2013. http:// hdrstats.undp.org/en/countries/profiles/PAK.html (accessed April 25, 2013).
Infectious diseases in Pakistan: a clear and present danger Published Online May 17, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)60248-2
Saeed Ahmad/Xinhua Press/Corbis
See Series page 2193
2138
Many diseases are common in Pakistan, including endemic and epidemic infectious diseases, emerging infections, and an increasing burden of non-communicable diseases. An estimated 8–9 million people in Pakistan are infected with the hepatitis C virus (HCV), increasing the risk of chronic liver disease and cancer.1 Another 620 000 people have tuberculosis, and every year 410 000 are newly infected and 59 000 die from the disease.2 500 000 cases of malaria arise every year, mostly in rural districts near the river Indus delta and in Baluchistan.3 Although HIV/AIDS prevalence remains below 1% in the general population, epidemics spread in the country’s estimated 135 000 injecting drug users (>40% of the injecting drug users in Faisalabad and Karachi are HIV infected) and transgender (hijra) sex workers (>10% infected in Karachi and Larkana).4,5 Poliomyelitis remains endemic despite an intense global focus to rid the virus from its last bastions
in Sindh, Baluchistan, and the districts bordering Afghanistan.6 Rabies still results in an estimated 5000 deaths every year.7 Dengue outbreaks in Lahore and Karachi have tested an already stretched health system, and perhaps diverted resources from other priorities after media attention.8 Weak health systems and ineffective regulation have exacerbated some epidemics. 15 years after the original reports about HCV transmission in Hafizabad, reuse of therapeutic needles and syringes in public and private facilities continues to drive the HCV epidemic, and contributes to the spread of HIV, as noted in Gujrat.9 National prevalence data for HCV (4·9%) and chronic hepatitis B virus (HBV; 2·5%) infection in the general population mask epidemics in small towns in the Punjab (>12% for HCV in Vehari and Hafizabad) and Baluchistan (>14% for HBV in Musakhel). Incomplete implementation of existing legislation for blood product safety is contributing to the spread of HCV and HBV.10,11 The 2015 Millennium Development Goals for tuberculosis, malaria, and HIV/AIDS in Pakistan remain elusive. Few patients are receiving treatment for drug-resistant tuberculosis, malaria, and HIV/AIDS, and increasing drug resistance is undermining future prospects for disease control. Today, fewer than 1000 of the estimated 9000 individuals infected with drug-resistant tuberculosis every year have been diagnosed and are undergoing treatment.2 Of 5256 registered people living with HIV/AIDS in 2011, fewer than half were receiving antiretroviral therapy.4 Low rates of bednet adoption in rural areas and poor vector control in urban centres contribute to continued transmission of malaria.3 www.thelancet.com Vol 381 June 22, 2013
Pakistan occupies a special place in global health for at least four reasons. First, Pakistan is a phenomenally research productive nation. The country’s imprint in The Lancet, for example, is extraordinary, and extends over many decades—from optimisimg the health of pregnant women,1 to improving case management of pneumonia,2 to identifying the potentially harmful effects of widely used micronutrient powders to prevent nutritional anaemia in children.3 Second, Pakistan’s medical and public health communities have delivered important innovations, such as school-based mentalhealth programmes4 and community-based Lady Health Workers,5 both of which have had important impacts on population health. The introduction of a new cadre of community health worker has had an especially important part to play in reducing stillbirths and newborn mortality, evidence that has had global reach. Third, Pakistan has produced leaders in health who have made a demonstrable difference both domestically and internationally—eg, identifying non-communicable diseases as a threat to the health of people in south Asia,6 signalling the dangers of abolishing Pakistan’s Ministry of Health,7 raising the alarm about substandard medicines,8 and mobilising the Muslim world to defeat polio.9 And finally, Pakistan’s health scientists have been the motive force behind important collaborations, such as Countdown to 2015 and the Partnership for Maternal, Newborn, and Child Health, which have transformed the international community’s response to health predicaments. For these reasons alone, Pakistan demands attention. But now, thanks to the able leadership of Sania Nishtar and her colleagues, especially Zulfiqar Bhutta, we take those reasons one step further by publishing four papers in a Series that examines the remarkable transitions in Pakistan’s health system.10–13 These transitions are important not only for Pakistan’s new Government, but also for a broader international audience that faces many of the same challenges that Pakistan confronts. Pakistan is classed by the annual UN Human Development Report as a “low human development” nation. In 2013, Pakistan was ranked 146 out of 186 countries, according to a Human Development Index that is a composite measure of income, education, and life expectancy.14 In this www.thelancet.com Vol 381 June 22, 2013
Lancet Series, we focus 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.10 Second, reproductive, maternal, newborn, and child health.11 Third, non-communicable diseases and injuries.12 And fourth, recommendations for future health reforms.13 Pakistan’s challenges are considerable. To take one example: nutrition. Almost half of Pakistan’s mothers and children are undernourished. Over 1·5 million children have acute malnutrition. And almost half of mothers are anaemic. The chronic effects of undernutrition are bad enough for health. But they also have a draining effect on the economy, with some estimates suggesting that malnutrition costs Pakistan 3% of its gross domestic product annually. The systematic failure to address nutrition is one that has endured in Pakistan for 40 years. It must be prioritised. In 2002, Pakistan initiated major reforms in its highereducation system. Although not without difficulties, these reforms changed the culture of academia to one that is focused on research, quality, and impact. It is surely time now for Pakistan to turn its attention to the health sector, especially since Pakistan is now the only country in the world without national governance for health. Thanks to Pakistan’s own vibrant professional, research, and civil society communities, solutions are available to politicians and policy makers alike, solutions that could quickly and decisively make a difference to the health of Pakistan’s population.
AP BK Bangash/AP/Press Association Images
Pakistan: health is an opportunity to be seized
Published Online May 17, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)60946-0 See Series pages 2193 and 2207 See Online/Series http://dx.doi.org/10.1016/ S0140-6736(13)60646-7 and http://dx.doi.org/10.1016/ S0140-6736(13)60813-2
Richard Horton The Lancet, London NW1 7BY, UK 1 2
3
4
5
Rab SM, Baseer A. Occult osteomalacia amongst healthy and pregnant women in Pakistan. Lancet 1976; 2: 1211–13. Bari A, Sadruddin S, Khan A, et al. Community case management of severe pneumonia with oral amoxicillin in children aged 2–59 months in Haripur district, Pakistan. Lancet 2011; 378: 1796–803. Soofi S, Cousens S, Iqbal SP, et al. Effect of provision of daily zinc and iron with several micronutrients on growth and morbidity among young children in Pakistan. Lancet 2013; published online April 18. http://dx.doi.org/ 10.1016/S0140-6736(13)60437-7. Rahman A, Mubbashar MH, Gater R, Goldberg D. Randomised trial of impact of school mental-health programme in rural Rawalpindi, Pakistan. Lancet 1998; 352: 1022–25. Bhutta ZA, Soofi S, Cousens S, et al. Improvement of perinatal and newborn care in rural Pakistan through community-based strategies. Lancet 2011; 377: 403–12.
2137
Comment
6
7 8 9
10
Jafa TH, Hatcher J, Poulter N, et al. Community-based interventions to promote blood pressure control in a developing country. Ann Intern Med 2009; 151: 593–601. Nishtar S, Mehboob AB. Pakistan prepares to abolish Ministry of Health. Lancet 2011; 378: 648–49. Nishtar S. Pakistan’s deadly cocktail of substandard drugs. Lancet 2012; 379: 1084–85. Ahmed QA, Nishtar S, Memish ZA. Poliomyelitis in Pakistan: time for the Muslim world to step in. Lancet 2013; published online April 24 http:// dx.doi.org/10.1016/S0140-6736(13)60764-3. Nishtar S, Boerma T, Amjad S, et al. Pakistan’s health system: performance and prospects after the 18th Constitutional Amendment. Lancet 2013; published online May 17. http://dx.doi.org/10.1016/S0140-6736(13)60019-7.
11
12
13
14
Bhutta ZA, Hafeez A, Rizvi A, et al. Reproductive, maternal, newborn, and child health in Pakistan: challenges and opportunities. Lancet 2013; published online May 17. http://dx.doi.org/10.1016/S0140-6736(12)61999-0. Jafar TH, Haaland BA, Rahman A, et al. Non-communicable diseases and injuries in Pakistan: strategic priorities. Lancet 2013; published online May 17. http://dx.doi.org/10.1016/S0140-6736(13)60646-7. Nishtar S, Bhutta ZA, Jafar TH, et al. Health reform in Pakistan: a call to action. Lancet 2013; published online May 17. http://dx.doi.org/10.1016/ S0140-6736(13)60813-2. United Nations Development Programme. Country profiles and international human development indicators. Pakistan. 2013. http:// hdrstats.undp.org/en/countries/profiles/PAK.html (accessed April 25, 2013).
Infectious diseases in Pakistan: a clear and present danger Published Online May 17, 2013 http://dx.doi.org/10.1016/ S0140-6736(13)60248-2
Saeed Ahmad/Xinhua Press/Corbis
See Series page 2193
2138
Many diseases are common in Pakistan, including endemic and epidemic infectious diseases, emerging infections, and an increasing burden of non-communicable diseases. An estimated 8–9 million people in Pakistan are infected with the hepatitis C virus (HCV), increasing the risk of chronic liver disease and cancer.1 Another 620 000 people have tuberculosis, and every year 410 000 are newly infected and 59 000 die from the disease.2 500 000 cases of malaria arise every year, mostly in rural districts near the river Indus delta and in Baluchistan.3 Although HIV/AIDS prevalence remains below 1% in the general population, epidemics spread in the country’s estimated 135 000 injecting drug users (>40% of the injecting drug users in Faisalabad and Karachi are HIV infected) and transgender (hijra) sex workers (>10% infected in Karachi and Larkana).4,5 Poliomyelitis remains endemic despite an intense global focus to rid the virus from its last bastions
in Sindh, Baluchistan, and the districts bordering Afghanistan.6 Rabies still results in an estimated 5000 deaths every year.7 Dengue outbreaks in Lahore and Karachi have tested an already stretched health system, and perhaps diverted resources from other priorities after media attention.8 Weak health systems and ineffective regulation have exacerbated some epidemics. 15 years after the original reports about HCV transmission in Hafizabad, reuse of therapeutic needles and syringes in public and private facilities continues to drive the HCV epidemic, and contributes to the spread of HIV, as noted in Gujrat.9 National prevalence data for HCV (4·9%) and chronic hepatitis B virus (HBV; 2·5%) infection in the general population mask epidemics in small towns in the Punjab (>12% for HCV in Vehari and Hafizabad) and Baluchistan (>14% for HBV in Musakhel). Incomplete implementation of existing legislation for blood product safety is contributing to the spread of HCV and HBV.10,11 The 2015 Millennium Development Goals for tuberculosis, malaria, and HIV/AIDS in Pakistan remain elusive. Few patients are receiving treatment for drug-resistant tuberculosis, malaria, and HIV/AIDS, and increasing drug resistance is undermining future prospects for disease control. Today, fewer than 1000 of the estimated 9000 individuals infected with drug-resistant tuberculosis every year have been diagnosed and are undergoing treatment.2 Of 5256 registered people living with HIV/AIDS in 2011, fewer than half were receiving antiretroviral therapy.4 Low rates of bednet adoption in rural areas and poor vector control in urban centres contribute to continued transmission of malaria.3 www.thelancet.com Vol 381 June 22, 2013