By Shehla AZ
The author is a policy
researcher and faculty member at a private medical university.
Published in Dawn,
October 14th, 2014.
ALL governments want to
spend public funds on schemes visible to the electorate. But the silent advance
of chronic non-communicable diseases (NCDs) demanding swift control has slipped
through the policy cracks.
Hypertension,
cardiovascular diseases, diabetes, lung diseases and cancers together are the
leading cause of deaths and disability in Pakistan, striking silently, causing
premature death, or lifelong complications.
Experts say Pakistan has
the seventh highest number of diabetics, 40pc of people over 40 years are
hypertensive, one to two persons out of 10 suffer from depression and,
annually, there are over 40,000 breast cancer deaths. Let us not dismiss these
as diseases of the wealthy or elderly. In fact, they strike the adult
productive population, especially the poor, in Pakistan. Economic losses from
lost days of work are huge and medical costs staggering.
The country is already
behind the MDGs in several areas. Simple targets such as vaccination coverage
for children and skilled providers for delivering babies have not been met.
Policy solutions for both uncontrolled chronic diseases and unfinished MDGs lie
at the primary healthcare level.
Boosting primary healthcare is key to fighting
NCDs.
How prepared are we to
control chronic diseases? Pakistan signed the global action plan for NCDs in
2011 aiming for a 25% reduction in NCD deaths, but did not implement it, while
other regional countries made rapid strides.
Perversely, the emphasis
in Pakistan has been on specialist hospitals, for example, putting in stents
for blocked arteries but overlooking in front-line clinics uncontrolled blood
pressure that cause failing hearts. Such strategies are listed as of lowest
priority by WHO, and involve up to 10 times the cost and lost opportunities of
continuing care at the frontline level. Even the well-endowed Gulf countries
put their monies into primary care interventions.
To give due credit, the
political parties’ manifestos mention primary care: PML-N and MQM twice, PTI
and PPP thrice and ANP four times. But the budgetary allocations underscore the
‘real’ policies of the health sector.
Health is a lucrative
sector as seen in the rapid increase in health budgets post devolution, but
primary care remains underfunded. The only hallmark effort was the Lady Health
Workers Programs in the 1990's by the Benazir Bhutto government.
The health sector’s
annual development plans for 2014-15 are typically tilted towards capital
schemes for specialist services — across the provinces 56% to 79% of
allocations are on hospitals, 17% to 36% on primary healthcare and 2% to 5% on governance.
High-end schemes such as
cardiac centers and interferon therapy, are visible and offer opportunity for
grafts taking priority away from ‘ordinary’ issues such as the Hepatitis B
vaccination to prevent liver cancer or the provision of fasting blood sugar
tests at Basic Health Units.
The purchase of a
month’s supply of medicine for either hypertension, depression or high blood
lipids, even cheap, generic drugs, is beyond the reach of many government
workers. And skills for the early management of simple chronic diseases are
weak even among st medics with studies showing that 41% of diabetes, 35% of
hypertensive and 31% of depression patients are given faulty prescriptions.
How can we contribute to
dealing with NCDs at the primary healthcare level? The best buys from other
countries are simple and cost-effective. First, Pakistan needs a core package
of health interventions whose per capita cost has been worked out. These would
include screening adults when they visit health facilities as in Oman;
expanding urban and rural health units to polyclinics as in Jordan, M-Health
messaging for patient follow-up as in India, referring risky cases to community
health workers as in Sri Lanka.
Second, health
interventions must be shifted from specialists to certified family physicians,
GPs and other front-line providers, backed with training and treatment
protocols.
Third, dedicated
governance structures, NCD units, at federal and provincial levels must be
established. Only Punjab has made a beginning so far.
Fourth, the private
sector needs to be co-opted through either training and accreditation or more
aggressive strategies such as regulation and contracting arrangements.
But given the complex
lifestyle linked with chronic diseases, action is also needed outside the
health sector, at the larger public policy level. Governments should establish
cross-sectorial forums at the planning and development level involving the
food, excise, road safety sectors etc. Simple policing has worked in other
countries — regulations for reducing salt content of processed foods; price
increase of saturated oils and carbonated drinks; safe footpaths, etc.
Yes, we have raised the
tax on cigarettes this budgetary year, but the test of political will lies in
the flow-back of some percentage of tax revenues to the health sector for NCD
control.
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