Health for all by the year 2000: can Pakistan meet the target?

Zaidi, S. Akbar

Since the late 1970s, the "Primary Health Care" (PHC)approach in order to deliver "Health for All by the Year 2000" (HFA/2000), has been in vogue in all the underdeveloped countries (UDCs) of the world. Nearly all the developed and underdeveloped countries endorsed the proposals set out by the World Health Organization (WHO) at its Conference in Alma Ata in 1978 (WHO 1978). The signing of the Alma Ata Charter supposedly signalled the beginning of a new era which would deal with the problems of health and disease of the great majority of the individuals of planet Earth.

Pakistan was also one of the signatories of the Alma Ata Charter and has since the signing, been in the forefront of the movement. Pakistan has become a spokesman for the PHC and HFA/2000 approaches at nearly all international seminars and conferences, and those who rule and can implement policies within the country, have continued giving both the policies active oral support. The Primary Health Care approach is, at least on paper, a fairly radical approach which sets out to deal with much more than the simple problems of the health of the poor of the world. It encompasses a very wide canvas, and issues, which apparently are not related directly to health care, also fall under its terms of reference. It is the purpose of this paper to see whether Pakistan can reach the goals of Health for All by the Year 2000, using the Primary Health Care approach, a goal to which it has committed itself totally.

II

Much has been written on what the PHC and HFA/2000 approaches involve and how a country should go about putting theory into practice. The basic components of the PHC programme have been succinctly summarised by Walt and Vaughan (1981), who argue that the PHC Scheme should have as prerequisites (i) equally accessible health facilities; (ii) active participation by the community; (iii) preventive rather than curative emphasis; (iv) appropriate technology; and (v) nutrition, water and education to be included in the whole approach. Using these requirements, we need to see how Pakistan has faired in achieving the aim of Health for All by the Year 2000.

The PHC approach requires health facilities to be equally accessible to all. A cursory look at the distribution of health facilities in Pakistan, gives a picture which is totally opposite to that required for implementing a PHC programme. At present, in Pakistan, we have 70 percent of the country's population living in rural areas where the distribution of health facilities paints a very grim picture : for the rural population, there are only 23 percent hospitals, 34 percent Mother and Child Health Centres, 18 percent beds, 15 percent of doctors, and 5 percent of nurses (Zaidi 1985). Thus, at the outset, we have health care system which is inaccessible to the vast majority of the rural inhabitants in Pakistan. Furthermore, inaccessibility in a free market system is also determined by one's purchasing power. For that population for whom health facilities are geographically available, the price tag on purchasing health care may make it inaccessible. Although Government hospital which deliver free medical care exist in large cities, the increase in population growth and the demand for services has outstripped the supply. Thus, private medical facilities fill the gap, but they are certainly not equally accessible to all. As Banerji, writing about India says, there are two almost parallel systems functioning, "one for the 'classes' and the other for the poor masses" Banerji (1984, p. 810).

Active participation by the community in determining and fulfilling their needs is surely a very positive and important ingredient to make the PHC programme successful. Unfortunately, in a country where the democratic tradition and process is severely controlled, active participation also loses its efficiency. Furthermore, when there is a dominant group in a certain area, the participation may be active only from their side when they can influence the outcome of the discussions. In traditional feudal societies such as ours, it is the landlord in the rural areas who determines where and what type of facilities will be situated. His choice, despite what the other participants say, will be the determining factor. William and Sato (1980) had exactly this sort of experience in the case of a pilot project in primary health care in Indonesia, where the landlord did not agree to the principle of equal participation when the decisions went against his interests. Women play the most important role in administering health care in the home, and where modern facilities are unavailable, as in much of Pakistan, their role is substantially enhanced. Thus their inclusion in any sort of community participation is imperative to make a primary health care programme even partially successful. However, the position of women in a highly religious and conservative society such as ours does not permit 'active community participation'.

It is quite clear that the disease pattern in underdeveloped countries is substantially different from that in the West. The main causes of death in Pakistan are as follows: infective and parasitic diseases, 54 percent; Malaria, 11 percent; death during birth, 7 percent; and tuberculosis, 6 percent (Government of Pakistan 1978, p. 614). The main killer of children is tetanus, followed by measles and dysentry (World Bank 1983). None of these diseases require grandiose hospitals stacked with the 'latest technology'. They simply require steps to eliminate the disease at the source. Water and sewerage play a major role in this process and the pattern in Pakistan is similar to that of other UDCs where "the most widespread diseases.... are those transmitted by human feces ... and ... these diseases spread most easily in areas without community water supply systems" (World Bank 1980 p. 13). In Pakistan in 1983, 77 percent of the urban and 22 percent of the rural population had access to potable water, while 48 percent of urban inhabitants and 4 percent of rural inhabitants had any access to sewerage and sanitation facilities (Zaidi 1985). Preventive measures such as inoculation also do not seem to reach the majority of the population. Of the 3 million babies born each year, less than 1.5 million received immunization, and then not all of these babies complete the immunization programme. Furthermore, the medical education pattern and the training done in the urban hospitals is very heavily dominated towards curing the patient and students do not interact with the community and thus fail to develop skills in preventive medicine. Their curriculum is also, mainly due to its western base, almost only curative-care oriented, where surgery and medicine receive much more emphasis than does the course in Community Medicine. This type of programme has resulted in the emphasis on doctors, and unfortunately, has minimised the role of much needed health auxiliaries (Zaidi: 1985; 1986a; 1986d; 1987b). Moreover, the role of the Government has not been very positive in developing health facilities which are preventive-oriented and it has shown a very clear bias in preferring to invest in high. technology hospitals and medical colleges rather than in Basic Health Units and Rural Health Centres which, due to their locational advantage and proximity to the population, can act as potential centres which play the lead role in administering and delivering preventive care (Zaidi 1985).

The technology in use in the health sector depends on the model of the health sector. The technology cannot be appropriate unless the model of health care is also appropriate. As has been argued above, the model of health care in Pakistan is biased towards the urban inhabitants, and to those who can afford to pay for the high cost of medical care. This emphasis has resulted in the development of an approach to health care which is modelled on the West. The Western model, which, with its peculiarities is appropriate for the developed countries, for reasons given above, does not suit the needs of the majority of the inhabitants of Pakistan who suffer from different diseases, and whose cures are substantially different. Thus, to talk of appropriate technology out .of the context of the health sector is meaningless, and the technology in use depends on the model that determines that use.

The fact that water, nutrition, housing and education have been included in the requirements for the PHC programme, underlines the fact that there is much more to health care than just medicines. They play an important part in health care, and their role is increased in the context of underdeveloped countries. The case of water has been discussed above and is of fundamental importance in the health matrix. With 6.4 individuals per room in Pakistan, one cannot speak of adequate housing conditions for the majority. As it is, this number is extremely high even if the inhabitants are healthy, but given the high incidence of disease in Pakistan, the condition is quite deplorable. Even if only one individual catches a communicable disease, he puts the other healthy individuals at great risk. Similarly, nutrition plays a major role in determining the health of an individual. This is more marked in the case of children, as malnutrition has been listed as a primary cause of death in children under the age of five years. Furthermore, nutritional deficiencies expose the child to diseases which he would not easily succumb to if he were popery nourished. Studies reveal that on the basis of a recommended dally allowance of 2550 calories per adult, 35 percent of the population in rural areas in Pakistan fails to reach this requirement (Irfan and Amjad 1984). As far as education is concerned, we see that the literacy rate in the country is only 26 percent, and the rate between 1972-1981 has shown only a marginal rise. The female literacy rate which is a very important factor in the health matrix is much worse than the overall rate : it is only 13 percent while in the rural areas it falls to a low of 5 percent, the primary school enrolment rate is only 50 percent and with a very high dropout rate, very few children acquire any functional literary and education.

III

Thus, one can see that Pakistan has so far not been able to achieve adequate targets which would put it on the road to achieve Health for All by the Year 2000, and thus it is more than likely that given the present structure of health care, that not only will Health not be available for All, but it is a possibility that the majority of the population will not have adequate health care by the end of the century. It is our contention that, not only has Pakistan not been heading in the right direction concerning Health for All, but that the system of health care, and the social, economic and political system which determines the system of health care is one in which it is unlikely to achieve Health for All by the end of the century, and what is essentially required is a different system which would make that likelihood possible. This point needs some elaboration.

The first prerequisite which is essential for achieving HFA/2000 is that facilities be more equitably distributed (i) to poor people, whether urban or rural, and (ii) to rural inhabitants. To alter the existing bias, two options are available (i) to cut the budget which is allocated to urban projects and/or (ii) to increase the overall budget and leave the ratio between urban and rural unchanged.

The sections of society who live in the cities, i.e., the bureaucrats, the elite, students, workers, and professionals, are all strong enough to exert pressure on the government to implement policies that would serve their interests. As it is, these sections, many of whom are well organized, are critical of the fact that the government is not doing enough to fulfill their needs, so the question of cutting the budget allocated for the urban areas does not arise. This is one reason why the government spends 6 times as much on health services in urban areas in Pakistan than it does on rural areas (Zaidi 1985). The second option is also problematic. In 1976, the government was spending 1.8 percent of GNP on the health sector. Today this ratio is down to 0.6 percent (World Bank 1983). This is indeed a substantial loss for the health sector and the amount Pakistan is spending on health, is almost one-ninth of the amount recommended by WHO. The government keeps reminding us that Pakistan is a poor country and we cannot afford to divert funds from elsewhere to the health sector and thus we must make do with what we have. The status quo remains and as long as the government pays heed mainly to the dominant sections in society, health services will remain inaccessible.

The desire to have a preventive system rather than a curative one also poses a number of structural problems. For one, the number of facilities in rural areas which can act as a delivery point for preventive care will have to be increased, and as we have just shown above, this may not be very easy. Furthermore, the presently curative-care, Western-hospital oriented approach to medicine will also have to be changed. The most important aspect of the present health system which will have to be changed is the teaching and training programme of medical students.

The present curriculum and training programme is modelled on a health system which is quite removed from the very different reality of Pakistan. As has been argued elsewhere, "medical students are taught about diseases which occur in the developed countries from books which are written by and for doctors whose societies are very different from those in underdeveloped countries" (Zaidi 1985 p. 477). The result is that the student is alienated from his environment and is not taught how to function in his local environment and is unable to deal with simple ailments even such as snake and dog bites. A curriculum which is designed to cater for the needs of the population of Pakistan will have to have a very great emphasis on preventive factors and on the use of community medicine. This will require taking medicine out of the few large urban hospitals and into the urban slums and rural communities.

Thus, a new model of health care will have to be developed which will indigenise health care and make it accessible to all the inhabitants of the country. In order to understand why these apparently simple steps are not implemented (a change in curriculum, greater community interaction, etc.), we need to see whose interests the present system serves, and how a new model will affect the dominance of these interests.

The present model of health care in Pakistan serves the interests of a very narrow section of society. A large part of this section is amongst the propertied and moneyed classes who are either in government (the bureaucracy, the army) or influence government policy (feudals, industrialists, professional etc.). The government must appease the dominant classes if it is to stay in office, and must provide them facilities and privileges in exchange for their support. Thus health facilities, like most other facilities in Pakistan, are focused around these dominant classes.

The income, wealth and the lifestyle of this elite differs substantially from that of the very great mass of their countrymen. The diseases of this class are also different from those of the poorer masses, where infectious and parasitic diseases which are fundamentally an outcome of the social and economic environment of the poor, ore replaced by the diseases of the developed countries or of the rich of the underdeveloped countries, and heart disease and cancer become the leading killers. Since the diseases of this class are different, the institutions required to cater for them will also be different. These diseases require specialised highly technical institutions with manpower which supplements these requirements. This means that the elitist system in Pakistan will, through its system of medical education, produce doctors who can primarily deal with the diseases of the rich. The curriculum will be heavily biased in terms of curative diseases and conditions found in urban areas. Such a system of medical education will produce a certain type of doctor who functions best in the social set-up based on the model and value of the dominant class.

Furthermore, there is a desire by the elite to produce the 'best' doctors and acquire the 'latest technology. This further distorts the already distorted health structure where we begin to produce doctors who wish to specialise in fields such as cardiovascular medicine and cancer since the latest gadgets are available in the country, while 80 percent of their countrymen die each year due to basic diseases whose cure is extremely simple and makes use of simple local technology. Thus, it is essentially this select elite which requires and acquires a certain type of health system which, for numerous reasons, excludes the great majority of the country's population.

Thus, if the dominant classes continue to determine the distribution of resources within the health sector, any attempt by the government of the day to seriously consider the PHC option will fail before it gets off the ground. The government may attempt to increase facilities and provide appropriately qualified doctors in rural areas but it will not be able to do so. It cannot cut the urban proportion of the health budget. It must, thus, bring in funds from some other sector. It will have difficulty in cutting the budget of the military or the bureaucracy as they will not permit that. Thus, it will have great difficulty in getting additional funds. If it were to attempt to alter the urban-based, curative-care medical education model, and produce a doctor more in tune with the needs of the urban poor, and of the rural inhabitants in general, the contradictions within the structure would also make these attempts fail. Most medical students belong to the privileged urban middle classes and their main aim is to maintain, if not improve, their class position (Zaidi 1986a; 1986b). They thus need (and wish) to acquire skills in line with the requirements of the moneyed classes. Under no conditions will they be willing to go to rural areas where they cannot expect to earn half of what they will in the cities (Zaidi 1986a). Further, attempts to restructure the curriculum content from one based on the Western-developed country model to an indigenous one will fail as this will not only "de-urbanize" the doctors but will also "de-internationalise" them. clearly, the middle and upper class medical students, the medical interest groups, and the dominant/ruling class at large will not permit such measures to curb their mobility.

In our discussion we have taken the view that the present model of health care in Pakistan is one which is determined by the interests of the elite whose requirements it fulfills. Thus as Navarro argues, "it can be postulated that it would be unhistorical to expect that changes towards equity can occur in the present distribution of resources, within and outside the health sector, without changing the economic and cultural dependence and the control by the defined social classes of those resources"(Navarro 1974 p. 22) (emphasis added). The governments commitment to primary health care and a promise to provide Health for All by the Year 2000 is only valid on paper, as the social and economic structure that determines the role of the elite in the health sector remains unchanged. This reality has to be dealt with if one intends to launch a successful PHC programme.

The examples of Mozambique, Vietnam, Cuba and Nicaragua illustrate that to begin with one has to change priorities from those focused on the elite to those focused on the people if there is a serious commitment towards Health for All. These countries have done precisely what the PHC approach requires: there has been active community participation in deciding what is best for the people. There has also been a genuine shift from a curative to a preventive care model and access-across region and class has indeed been made equitable and there have been intensive programmes which provide better water, sanitation, housing, nutrition and education to the people so that the entire health matrix is incorporated (Gish 1983; Walt and Melamed 1983; Jelley and Madelay 1984). However, a prerequisite for bringing in these changes was a substantial transformation of the previous health system with its distorted priorities. It has to be understood that the health system could be changed only after the vested interests behind the system were removed. This basic prerequisite was dealt with before the PHC concept could be successfully implemented.

IV

The population of Pakistan in the year 2000 will be in excess of 130 million people. This paper has attempted to deal with a theme which will affect not only the 130 million, but their generations to come. The health of individuals and nations plays an extremely important role in determining their future and thus every government must rightly be concerned with this issue.

The government of Pakistan has, for the last nine years, spoken of the commitment to its people that it will provide health care to all of them by the end of the century. Given the social and economic conditions, and the pattern of disease in Pakistan, the primary health care approach is the most viable one to reach the goal of Health for All. The PHC approach is a radical approach which attempts to change the existing inequitable health system and brings it in line with the requirements of the majority of the 130 million.

The existing model of health care serves the interests of a very select minority, who are not necessarily concerned with the welfare of the masses. If a PHC programme was successfully implemented in Pakistan, one would have to change the existing health system in the country, thus forcing the elite to lose their privilege. This they are not willing to do. Thus, we do not have a change in the health system, and thus, the PHC approach cannot be implemented easily and in Pakistan exists only on paper. And unfortunately, the year 2000 Will not bring with it health care for the majority of Pakistanis, and Health for All will remain a very distant dream.

Comments on "Health for All by the Year 2000: Can Pakistan Meet the Target?"

Akbar Zaidi's paper asks an extremely important and critical question. Two points are made forcefully and articulately. First, that the status quo of the health system persists with all its bias in favour of urban elites with that faction of society in position of power to decide health for whom. Second, it is the author's contention that unless society undergoes political transformation, this situation is unlikely to change and, accordingly, he reaches the conclusion that health for all by the year 2000 is improbable. To ask whether Pakistan will arrive at the goal of Health for All by 2000 means relying mainly on speculation. The author may have been better off when undertaking an academic exercise in asking the questions (1)whether there has been any change in strategy on the part of the government to provide health for a greater portion of the populace, and (2) whether trends in mortality and morbidity showed any supporting evidence of improved health coverage since 1978 (the year when Pakistan became a signatory to the Alma Ata agreement). The reason why I say this is because the criticisms the author cites of the health system have applied to Pakistan since its inception but nevertheless, changes in mortality have occured since then. These have been brought about by an extensive use of antibiotics, vaccines, and simple public health measures, all of which have led to a decline in mortality. So, when studied historically, the picture that emerges is quite different where virtually the same health system as the one we have today, with all its shortcomings, particularly its urban bias, has been effective to quite a degree. Further, mortality declines may occur again. In fact, this may have done already with the immunization campaign launched by the government which should have a reductive impact on infant mortality and, subsequently, on crude death rates. The author generally seems unaware of hard evidence which is available for doing some evaluation of whether the relatively more recent policies in the health sector are affecting mortality and morbidity.

The author, repeatedly, refers to the unsuitability of the "Western influenced" health system for Pakistan's need. But he himself is falling in the same trap of measuring success of primary health care only through the access to hospitals, health centres, and training of doctors. He neglects to mention the parallel system of indigenous health workers in whom the majority of the Pakistani populace have faith much above that in doctors. Particularly, when using access to health facilities in Pakistan as a measure of improvement, I think we have to also keep in mind psychological access. There is evidence from a National Health Survey conducted by the Federal Bureau of Statistics (FBS) in 1983 that even where a health facility existed in the vicinity, its utilization by the community was quite low. Also, evidence from a study done using the data shows that the infant mortality rate in fact does not vary significantly in districts where there is no hospital or dispensary, compared to where there is such a facility. Therefore, by just improving the availability of health services may in itself not to be enough to bring about declines in mortality and morbidity.

In the same vein, the author also fails to incorporate into his discussion the particular gender differentials in health care of mortality which particularly apply in Pakistan whereas he mentions women to be important because they are half the population, he does not expand on this important theme. Cultural factors which restrict women's movement and lead to limited psychological and physical access are considered important determinants of gender differentials in mortality which even apply in urban areas. The gender bias of the health system may effectively be as serious a hindrance to Health for All by 2000 as class biases of the health system.

The author quite rightly points out that the disease pattern in underdeveloped countries is substantially different from the West. The diseases prevalent here, such as malaria, tetanus etc. do not need 'high-tech' to be eliminated. I think this is fortuitious from the point of view of whether Pakistan can improve its health performance with relative ease. It implies that simple and relatively, inexpensive public health measures can still bring about substantial declines in mortality and morbidity. I do not necessarily agree with the author that consequently we can afford to do away with "grandiose hospitals stacked with the latest technology".

I feel the author is totally underrating the role of recent health interventions by the government, particularly the huge immunization programme, and exaggerating the harm brought upon by the "Western base" of the curriculum of medical students. Rural health centres have been expanded substantially during the Sixth Five Year Plan period and dispensaries have been upgraded. To make an unbiased and just evaluation of the government's intent and efforts in the health sector, the author ought to evaluate the impact of these newer inputs such as Oral Rehyderation Therapy (ORT), co-opting of hakims, training of Traditional Birth Attendants (TBAs) and then measure it against the negatives--i.e. inequitable distribution of health care sources, inadequate facilities in remote areas, inadequate water supply, etc. The analysis presented does not benefit from the repeated mention of a few of the ills of our health system which may be the most resistant to change. I noticed that Akbar had written a similar paper for last year's conference and the discussant (Shamim Sahibzada) comments were that he should look:

1. At the role of the private sector in health--which he neglects to do. As recently researched this is playing an increasing role particularly in the urban areas.

2. Look at evaluation and appraisal of successful projects in the health sector, I know that UNICEF has been undertaking such studies particularly to evaluate dai training and immunization. Similarly, underutilization of existing health facilities is a critical area of concern.

Obviously, the author by writing two papers on a similar theme shows a commitment to research on this particular question. I feel, therefore, that he would have benefited greatly had he incorporated the previous discussant's comments into this year's paper.

I think most of us would tend to agree with Akbar Zaidi's conclusion that Pakistan will not achieve Health for All by the Year 2000 but not with his premise that, notwithstanding, radical socio-economic changes, this goal is impossible. I agree totally with Shamim Sahibzada's comment that a utopian solution is not always the only one, much can be achieved by way of public health education about use of water, sanitation, ORS, personal hygiene through TV and Radio. I may add that projects such as the Orangi Pilot Project and the UNICEF Project at Baldia, both based in Karachi's Katchi abadis, present impressive models of how a small degree of intervention has led to very successful implementation of sanitation, health and education projects, by a very poor community itself making most of the investment. The author, may for future reference, be able to make some positive suggestions to put Pakistan on the right road to Health for All by the Year 2000, by studying the evaluation reports of these projects.

Zeba A. Sathar

Pakistan Institute of Development Economics, Islamabad

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S. AKBAR ZAIDI, The author is Research Economist at the Applied Economics Research Centre, Karachi.