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Improving health: can Pakistan prioritise?
Correspondence
Reuters
Sania Nishtar and Ahmed Mehboob’s discussion of the abolition of the Health Ministry in Pakistan1 raises the question of whether the health care problems in Pakistan could be solved by such a move. The expansion and development of the health sector in Pakistan has never involved strategic, policy, or longterm planning. Since the early 1960s, development has occurred in the context of 5-year or 1-year plans. Only in 1997 was the first national health policy announced, the aim being “Health for all by 2010”. The slogan soon changed to “Health for all by 2020”. Perplexingly, although Pakistan has a higher gross national product per capita than neighbouring south Asian countries,2 it falls far behind the averages for low-income countries on health indicators such as infant, child, and maternal mortality.3 Poor health status is partly explained by poverty, low levels of education, the low status of women in large segments of society, and inadequate sanitation.4 But it is also related to serious deficiencies in health services, both public and private. Pakistan’s health system is crippled by chronic underinvestment in facilities and staff, with only 2% total expenditure of gross domestic product on health.5 Governance of the health sector is adversely affected by frequent changes in government, with each prime minister appointing their own staff, from cleaners to health ministers. Corruption, feudalism, and high rates of illiteracy are other factors in Pakistan’s inability to develop a more effective and efficient health system. The barriers are many, and can produce a sense of helplessness and futility. Failing to improve, we feel unfortunate and wish that someone, somewhere, would give us that missing link or resource that we imagine would make change possible. Changing or demolishing health ministries is unlikely to help, since the people are the same, with their lack of insight. “We want to make health care well”, goes the complaint, “but they won’t let us”. 410
We declare that we have no conflicts of interest.
*Sunita Dodani, Rashid A Chotani [email protected] Center for Post Polio Rehabilitation, Leawood, KS 66209, USA (SD); and Uniformed Services University of Health Systems, Bethesda, MD, USA (RAC) 1
2 3 4
5
Nishtar S, Mehboob AB. Pakistan prepares to abolish Ministry of Health. Lancet 2011; 378: 648–49. Ministry of Health. National health policy. Islamabad: Government of Pakistan, 1997. Tinker AG. Improving women’s health in Pakistan. Washington, DC: World Bank, 1998. Health, Nutrition and Population Unit, South Asia. Pakistan: towards a health sector strategy. Washington, DC: World Bank, 1998. WHO. Pakistan statistics. http://www.who.int/ countries/pak/en/ (accessed Nov 30, 2011).
Improving health: can Pakistan prioritise? Pakistan lags far behind in meeting the Millennium Development Goals. Neonatal mortality is responsible for 57% of all deaths in children younger than 5 years in the country, and Pakistan has the highest neonatal mortality rate in the region.1 The under-5 mortality rate has decreased by 24% since 1990. However, both rates have remained more or less static in the poorest income quintile.2 With the devolution of the Ministry of Health last year, Pakistan faces the challenge of developing the much needed provincial infrastructure that would integrate the comprehensive efforts of various stakeholders in promoting better health outcomes. Some reassessment of budgetary priorities will be needed. In 2010, Pakistan faced monsoon floods that killed more than 1700 people and displaced 20 million, plus the loss of infrastructure, livestock, agriculture, and housing worth billions of dollars. The Government put the reconstruction cost at Rs578 billion. However, the two smallest allocations were Rs4 billion for health sector reconstruction and Rs2 billion for disaster risk management.2 Furthermore, during the past decade, Pakistan’s economy has incurred enormous indirect and direct costs of the “war on terror”, amounting to
Rs5037 billion (US$67·93 billion).3 Conflict in the country has coincided with a plummeting of the ratio of investment to gross domestic product (GDP) from 22·5% in 2006–07 to 13·4% in 2010–11, with grave consequences for jobs.3 The challenge lies with increasing productive capacity, which in turn relies on peace in the region to attract investment.3 Since 2006, Pakistan has been spending between 3·0% and 3·8% of its GDP on the military—ie, not much less than the 4·0–4·7% spent by the much richer USA.4 This has drawn resources away from the health sector, on which Pakistan spent a mere 2·6% of GDP in 2009 (compared with 16·2% for the USA);4 the government contribution is about 0·85%. For a developing country, Pakistan needs to rethink its priorities and redirect some of its military spending towards improving the basic human needs of its people. I declare that I have no conflicts of interest.
Sabeena Jalal [email protected] Harvard University, Boston, MA 02446, USA 1
2
3
4
Baley T, Couffinhal A, Haq I, Kazi S, Loevinsohn B. Pakistan sector report: delivering better health services to Pakistan’s poor. Washington, DC: World Bank, 2010. Pakistan Ministry of Finance. Economic survey 2010: flood impact assessment. Islamabad: Planning Commission, 2010. Pakistan Ministry of Finance. Economic survey 2010: cost of war on terror for Pakistan economy. Islamabad: Planning Commission, 2010. World Bank. World development indicators. http://data.worldbank.org/indicator/all (accessed Nov 30, 2011).
Non-communicable diseases and the food and beverage industry The International Food & Beverage Alliance (IFBA) includes ten global food and non-alcoholic beverage manufacturers (Coca-Cola Company, Ferrero, General Mills, Grupo Bimbo, Kellogg’s, Kraft Foods, Mars, Nestlé, PepsiCo, and Unilever). Although we cannot speak for the entire food and non-alcoholic beverage industry, nor any www.thelancet.com Vol 379 February 4, 2012
Reuters
Sania Nishtar and Ahmed Mehboob’s discussion of the abolition of the Health Ministry in Pakistan1 raises the question of whether the health care problems in Pakistan could be solved by such a move. The expansion and development of the health sector in Pakistan has never involved strategic, policy, or longterm planning. Since the early 1960s, development has occurred in the context of 5-year or 1-year plans. Only in 1997 was the first national health policy announced, the aim being “Health for all by 2010”. The slogan soon changed to “Health for all by 2020”. Perplexingly, although Pakistan has a higher gross national product per capita than neighbouring south Asian countries,2 it falls far behind the averages for low-income countries on health indicators such as infant, child, and maternal mortality.3 Poor health status is partly explained by poverty, low levels of education, the low status of women in large segments of society, and inadequate sanitation.4 But it is also related to serious deficiencies in health services, both public and private. Pakistan’s health system is crippled by chronic underinvestment in facilities and staff, with only 2% total expenditure of gross domestic product on health.5 Governance of the health sector is adversely affected by frequent changes in government, with each prime minister appointing their own staff, from cleaners to health ministers. Corruption, feudalism, and high rates of illiteracy are other factors in Pakistan’s inability to develop a more effective and efficient health system. The barriers are many, and can produce a sense of helplessness and futility. Failing to improve, we feel unfortunate and wish that someone, somewhere, would give us that missing link or resource that we imagine would make change possible. Changing or demolishing health ministries is unlikely to help, since the people are the same, with their lack of insight. “We want to make health care well”, goes the complaint, “but they won’t let us”. 410
We declare that we have no conflicts of interest.
*Sunita Dodani, Rashid A Chotani [email protected] Center for Post Polio Rehabilitation, Leawood, KS 66209, USA (SD); and Uniformed Services University of Health Systems, Bethesda, MD, USA (RAC) 1
2 3 4
5
Nishtar S, Mehboob AB. Pakistan prepares to abolish Ministry of Health. Lancet 2011; 378: 648–49. Ministry of Health. National health policy. Islamabad: Government of Pakistan, 1997. Tinker AG. Improving women’s health in Pakistan. Washington, DC: World Bank, 1998. Health, Nutrition and Population Unit, South Asia. Pakistan: towards a health sector strategy. Washington, DC: World Bank, 1998. WHO. Pakistan statistics. http://www.who.int/ countries/pak/en/ (accessed Nov 30, 2011).
Improving health: can Pakistan prioritise? Pakistan lags far behind in meeting the Millennium Development Goals. Neonatal mortality is responsible for 57% of all deaths in children younger than 5 years in the country, and Pakistan has the highest neonatal mortality rate in the region.1 The under-5 mortality rate has decreased by 24% since 1990. However, both rates have remained more or less static in the poorest income quintile.2 With the devolution of the Ministry of Health last year, Pakistan faces the challenge of developing the much needed provincial infrastructure that would integrate the comprehensive efforts of various stakeholders in promoting better health outcomes. Some reassessment of budgetary priorities will be needed. In 2010, Pakistan faced monsoon floods that killed more than 1700 people and displaced 20 million, plus the loss of infrastructure, livestock, agriculture, and housing worth billions of dollars. The Government put the reconstruction cost at Rs578 billion. However, the two smallest allocations were Rs4 billion for health sector reconstruction and Rs2 billion for disaster risk management.2 Furthermore, during the past decade, Pakistan’s economy has incurred enormous indirect and direct costs of the “war on terror”, amounting to
Rs5037 billion (US$67·93 billion).3 Conflict in the country has coincided with a plummeting of the ratio of investment to gross domestic product (GDP) from 22·5% in 2006–07 to 13·4% in 2010–11, with grave consequences for jobs.3 The challenge lies with increasing productive capacity, which in turn relies on peace in the region to attract investment.3 Since 2006, Pakistan has been spending between 3·0% and 3·8% of its GDP on the military—ie, not much less than the 4·0–4·7% spent by the much richer USA.4 This has drawn resources away from the health sector, on which Pakistan spent a mere 2·6% of GDP in 2009 (compared with 16·2% for the USA);4 the government contribution is about 0·85%. For a developing country, Pakistan needs to rethink its priorities and redirect some of its military spending towards improving the basic human needs of its people. I declare that I have no conflicts of interest.
Sabeena Jalal [email protected] Harvard University, Boston, MA 02446, USA 1
2
3
4
Baley T, Couffinhal A, Haq I, Kazi S, Loevinsohn B. Pakistan sector report: delivering better health services to Pakistan’s poor. Washington, DC: World Bank, 2010. Pakistan Ministry of Finance. Economic survey 2010: flood impact assessment. Islamabad: Planning Commission, 2010. Pakistan Ministry of Finance. Economic survey 2010: cost of war on terror for Pakistan economy. Islamabad: Planning Commission, 2010. World Bank. World development indicators. http://data.worldbank.org/indicator/all (accessed Nov 30, 2011).
Non-communicable diseases and the food and beverage industry The International Food & Beverage Alliance (IFBA) includes ten global food and non-alcoholic beverage manufacturers (Coca-Cola Company, Ferrero, General Mills, Grupo Bimbo, Kellogg’s, Kraft Foods, Mars, Nestlé, PepsiCo, and Unilever). Although we cannot speak for the entire food and non-alcoholic beverage industry, nor any www.thelancet.com Vol 379 February 4, 2012