Healthcare in Pakistan

Healthcare in Pakistan is administered mainly in the private sector which accounts for approximately 80% of all outpatient visits.[1] The public sector was until recently led by the Ministry of Health, however the Ministry was abolished in June 2011 and all health responsibilities (mainly planning and fund allocation) were devolved to provincial Health Departments which had until now been the main executors of public sector health programs. Like other South Asian countries, health and sanitation infrastructure is adequate in urban areas but is generally poor in rural areas.

Pakistan's health care delivery system includes both state and non-state; and profit and not for profit service provision. Studies have shown that Pakistan's private sector healthcare system is outperforming public sector healthcare system in terms of service quality and patient satisfaction.[2] The provincial and district health departments, para-statal organizations, social security institutions, non-governmental organizations (NGOs) and private sector finance and provide services mostly through vertically managed disease-specific mechanisms. The country’s health sector is also marked by urban-rural disparities in healthcare delivery and an imbalance in the health workforce, with insufficient health managers, nurses, paramedics and skilled birth attendants in the peripheral areas.[3] Healthcare delivery system of Pakistan is rather complex which includes healthcare sub-systems by federal governments and provincial governments competing formal and informal private sector healthcare systems.[4] In 2018, Saad Ahmed Javed and Dr. Sifeng Liu proposed, much awaited, the first "comprehensive structure of the Healthcare Delivery System of Pakistan".[4]

Pakistan per capita income (PPP current international $, 2013) is 5,041[5] and the total expenditure on health per capita (intl $, 2014) is 129 which is only 2.6% of GDP (2014)[6]

Cancer care

Cancer information on Pakistan [7] Approximately one in every 9 Pakistani women is likely to suffer from breast cancer which is one of the highest incidence rates in Asia.[8]

Major cancer centers in Pakistan include the Shaukat Khanum Cancer Hospital & Research Center in Lahore and Peshawar, Aga Khan University Hospital in Karachi and the National Institute of Blood Diseases (NIBD) in Karachi.

Obesity

Malnutrition

Malnutrition is one of the most significant public health problems in Pakistan, and especially among children. According to UNICEF, about half of children are chronically malnourished.[9] National surveys show that for almost three decades, the rates of stunting and acute undernutrition in children under five years of age have remained stagnant, at 45 percent and 16 percent, respectively.[10] Additionally, at the “national level almost 40% of these children are underweight...and about 9% [are affected] by wasting”, diseases where muscle and fat tissues degenerate as a result of malnutrition.[11] Similarly, women are also at risk, with about half suffering from anemia, which is commonly caused by iron deficiency.[12]

A significant contributing factor to this issue is food insecurity; The World Food Programme estimates that nearly one in two Pakistanis are at risk of food insecurity.[13] This in turn can be attributed in part to the rapid urbanisation and mass migrations caused by the Great Partition of India and Pakistan, and the resulting issues with infrastructure and government, as well as other factors.

For example, contamination of water sources affects water and food security, and also over a long time contribute to stunting and underweight measurements, caused by deficiencies of nutrients, lost through diarrhea, dysentery, and other water-born diseases.[14]

Some limitations to interventions and aid are due to the limitations in peer-reviewed literature on this specific topic. According to the director of the nutritional science program at Pakistan’s Dow University of Health Sciences (DUHS), and president of the Pakistan Nutrition and Dietetic Society (PNDS), Dr. Safdar, “only 99 papers of nutritional research were published in Pakistan between 1965 and 2003”.[15]

Smoking

Drug addiction

Suicide

Cancer

Among Asian countries, Pakistan has the highest rates of breast and ovarian cancer. The genetic findings show that BRCA mutation (BRCA1 and BRCA2) mutations account for a substantial proportion of hereditary breast/ovarian cancer and early-onset breast and ovarian cancer cases in Pakistan.[16] Breast cancer is the most common cancer in Pakistan as different studies show it kills nearly 40,000 women every year. According to World Health Organization (WHO), breast cancer rates are getting worse and it is not sparing even younger age group.[17]

Mental Health

Introduction:

Mental health is the most neglected field in Pakistan where 10- 16% of the population, more than 14 million, suffers from mild to moderate psychiatric illness, majority of which are women.[18] The figures probably do not include a large number of people who have never seen a psychiatrist and who strongly deny the need for psychiatric consultation.[19]

The incidence and prevalence have both increased tremendously in the background of growing insecurity, terrorism, economical problems, political uncertainty, unemployment, stressful working conditions, gender discrimination, unhealthy lifestyle, physical ill health, genetic factors, unrestricted urbanisation, and disruption of the social fabric and loss of protective family networks. Sinking below poverty line by almost 39% of the individuals is an alarming factor worth noting.[18]

Legislation and Policy:

When Pakistan was created in 1947, the newly created state continued with the Lunacy Act of 1912, which had been in place in British India. The focus of the act was more on detention than on treatment and with advances in treatment, especially the introduction of psychotropic medication, updated legislation was needed but it was not until 2001 that the Lunacy Act of 1912 was replaced by the Mental Health Ordinance of 2001.[20] Following the 18th amendment in the constitution of Pakistan, health was made a provincial subject rather than a federal one. On 8 April 2010, the Federal Mental Health Authority was dissolved and responsibilities were devolved to the provinces, and it became their task to pass appropriate mental health legislation through their respective assemblies.Only the provinces of Sindh and Punjab have a mental health act in place and there is an urgent need for similar legislative frameworks in other provinces to protect the rights of those with mental illness.[20]

Pakistan's mental health policy was last revised in 2003.The disaster/emergency preparedness plan for mental health was last revised in 2006.[21] There is no policy that protects the rights of people who get convicted but are mentally ill. Recently, Pakistan’s top court has ruled that schizophrenia does not fall within its legal definition of mental disorders, clearing the way for the execution, of a mentally ill man convicted of murder.[22][23]

Mental Health Care Services:

The allocated mental health budget is 0.4% of total health care expenditures.[24] Estimated mental health spending per capita is (US$) $0.01.[21] They are only 5 mental hospitals in Pakistan.[21]

Number of  Mental health outpatient facility 4,356 and  number of mental health day-treatment facility is 14.[21] There are 18 NGOs in the country involved in individual assistance activities such as counselling, housing or support groups.[25] The total number of human resources working in mental health facilities or private practice per 100,000 population is 87.023, among which 342 are  psychiatrist. meaning that there is roughly one psychiatrist available per half-million people.Of these, 45% work for government-run mental health facilities and 51% work with non-governmental organisation s and other private institutions, while 4% work in both sectors.[26][19][27] This shows that infrastructure does not meet the population needs for mental health care.

Disease Burden of Mental Health:

Burden of mental disorders  in terms of Disability-adjusted life years (per 100,000 population) is 2,430.[21] Common mental health problems have been identified in both the rural and urban population which seems to have a positive association with socio-economic adversities, relationship problems and lack of social support. Depressive and anxiety disorders appear to be highest  followed by bipolar disorder, schizophrenia, psychosomatic disorders, obsessive compulsive disorder and post-traumatic stress disorder.[28]

Percentage of DALYS of common mental disorders in Pakistan
MENTAL DISORDERS DALYS
Schizophrenia 0.36%
Alcohol use disorders 0.47%
Drug use disorders 0.70%
Depressive Disorders 1.28%
Bipolar disorders 0.27%
Anxiety disorders 0.89%
Eating disorders 0.06%
Autistic Spectrum 0.33%
ADHD 0.01%
Conduct disorder 0.26%
Intellectual Disability 0.21%
Other mental disorders. 0.32%

Depression often starts at young age and affects women more commonly than men. One or two mothers out of 10 have depression after childbirth. Depression also limits a mother’s capacity to care for her child, and can seriously affect the child’s growth and development.[18] A study showed that exposure to maternal mental distress is associated with undernutrition in 9‐month infants in urban Pakistan.[29]

Almost 18,000 people in Pakistan commit suicide annually while the number of suicide attempts is almost four times greater than these figures.[30] Suicide prevalence in Pakistan is 9.3 people per 100,000 persons.[21]

According to United Nations Office on Drugs and Crime (UNODC) technical summary report 2012 on drug use in Pakistan, annual prevalence is estimated to be 5.8 per cent, or 6.45 million of the population in Pakistan aged between 15 and 64 used drugs in 2012. Cannabis is the most commonly used drug with an annual prevalence of 3.6 per cent or approximately four million people. Cannabis is followed by sedatives and tranquillisers, such as benzodiazepines, heroin, opium and other opiates.[25]

Mental health Awareness

Challenges and Necessary Actions:

The stigma against mental illness is rampant in Pakistan. It is sustained by popular belief in spiritual cures — exorcising evil spirits, experimenting with herbal cures and reciting verses from the Quran — and a lack of awareness about mental illness’s causes, symptoms and cures.Even when patients recognise their symptoms, overcome the stigma, gain the support of their families and start looking for medical help, there simply isn’t much help to be had.[31][19]

It is concluded that health care system’s response in Pakistan is not adequate to meet the current challenges and that changes in policy are needed. Mental health care needs to be incorporated as a core service in primary care and supported by specialist services.[28] Political commitment, adequate human and financial resources, and advocacy are needed for the integration of mental health into PHC in Pakistan.[32]

Public awareness programs addressing mental health issues should be launched through media.The focus should be on promoting mental health throughout the lifespan to ensure a healthy start in life for children to prevent mental disorders in adulthood and old age.Mechanisms to monitor human rights should be established to protect people from inhuman and degrading treatment. There is a need of socio-economic empowerment of women by improving access to education and microcredit schemes. Community and day centres should be built for them at district level and stress prevention programs should be started at work.[18]

There is a strong need to provide adequate training for general practitioners and postgraduate training for mental health professionals to meet the current demands. A collaborative network between stakeholders in the public and private sector, as well as non-governmental organisations are required that promotes mental health care and advocates for changes in mental health policy.[20][28]

Ongoing Programs:

A number of innovative programmes to develop indigenous models of care like the 'Community Mental Health Programme' and 'Schools Mental Health Programme' have been developed by the Pakistan government. These programmes have been found effective in reducing stigma and increase awareness of mental illness amongst the adults and children living in rural areas.[33]

Recently, WHO launched a mental health Gap Action Program (mhGAP). It will call for improving political commitments and help develop policies, and legislative infrastructure, to provide integrated health care.[30]

Also,The British BasicNeeds program, mental health focused international NGO with a global reach spanning 14 countries, began forming partnerships with Pakistani nonprofits in 2013, has already served 12,000 people in need of psychiatric attention. In addition to setting up camps where patients can see doctors, receive prescriptions for medicines and engage in therapy, the program trains citizens to recognise symptoms and side effects of mental illnesses.[34][31]

Resources

Personnel (source)
Doctors (2009)139,555
Dentists (2009)9,822
Nurses (2009)69,313
Midwives (2009)26,225
Health visitors (2009)10,731
Registered vets (2009)4,800
Health facilities in 2009 (source)
Total Health Facilities13,937103,708 beds
Hospitals96884,257 beds
Dispensaries4,8132,845 beds
Rural health centers5729,612 beds
Tuberculosis clinic293184 beds
Basic health units5,3456,555 beds
M.C.H. centers906256 beds

Personnel

According to official data, there are 127,859 doctors and 12,804 health facilities in the country to cater for over 170 million people.[35]

Many Pakistani doctors and medical professionals choose to migrate to other countries, contributing to a brain drain and chronic skills shortage in the country. In the United States alone, there are over 17,000 doctors of Pakistani origin.[36] Pakistan is the fourth highest source of International medical graduate doctors in the U.S[37] as well as the fourth highest source of foreign dentists licensed in the United States.[38]

Facilities

Professional institutes

As of 2007, there were 48 medical colleges and 21 dental colleges in the country.[39]

Services

Nursing

According to Dr.Shaikh Tanveer Ahmed Nursing is a major component of health care in Pakistan. The topic has been the subject of extensive historical studies,[40] is as of 2009 a major issue in that country,[41] and has been the subject of much scholarly discussion amongst academics and practitioners.[42] In 2009, Pakistan’s government stated its intent to improve the country's nursing care.[43]

Dentistry

At present there are upwards of 70 dental schools (public and private) throughout Pakistan, according to the Pakistan Medical and Dental Council the state regulatory body has upwards of 11500 registered dentists. The four-year training culminates in achieving a Bachelor of Dental Surgery (BDS) degree, which requires a further one year compulsory internship to be a registered dentist in Pakistan.

Pharmacy

Medical tourism

Community medicine

Pakistan is committed to the goal of making its population healthier, as evidenced by the continuing strong support for the Social Action Program (SAP) and by the new vision for health, nutrition, and population outlined in the National Health Policy Guidelines published by the government.

  • Lady health workers: A recent initiative, lady health worker, has turned out to be a promising community-based health worker program. These workers bring health information, some basic health care and family planning services to doorsteps of women. Presently, 96,000 women are serving as in this initiative in their home villages.[44]

In recent times, the startup culture in Pakistan has boomed with many players trying to change the healthcare segment as well. Some of the examples include InstaCare,MyDoctor.pk (now oladoc),[45][46] Sehat Kahani,[47] Marham[48] and Hayaat.pk. These startups are also helping patients to buy medicines online, order Lab tests and get home sample collection done and maintain medical records so that all patient data & history is stored in one place.

All of the above mentioned are services which were earlier just not available to patients in Pakistan and hopefully their access will become easier and simpler for the masses as time progresses.

Healthcare Delivery System

Healthcare Delivery System of Pakistan [49][50]

Healthcare delivery system of Pakistan is complex and both state and non-state actors play their role in delivering healthcare services, which is primarily the responsibility of state according to the Constitution of Pakistan.[2] In 2018, a team of healthcare researchers at a Chinese university proposed the first "comprehensive healthcare delivery system" of Pakistan.[4]

See also

References

  1. ↑ Khan, Ahmed. "Pakistan Economic Survey 2010-11: Health and Nutrition". finance.gov.pk. Government of Pakistan, Ministry of Finance. Retrieved 7 February 2018.
  2. 1 2 Javed, Saad Ahmed; Liu, Sifeng; Mahmoudi, Amin; Nawaz, Muhammad (2018-08-30). "Patients' satisfaction and public and private sectors' health care service quality in Pakistan: Application of grey decision analysis approaches". The International Journal of Health Planning and Management. doi:10.1002/hpm.2629. ISSN 0749-6753.
  3. ↑ (PDF) http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_pak_en.pdf. |first1= missing |last1= in Authors list (help); Missing or empty |title= (help)
  4. 1 2 3 Javed, Saad Ahmed; Liu, Sifeng (2018-10-08). "Evaluation of outpatient satisfaction and service quality of Pakistani healthcare projects". Grey Systems: Theory and Application. 8 (4): 462–480. doi:10.1108/gs-04-2018-0018. ISSN 2043-9377.
  5. ↑ "world bank".
  6. ↑ "who".
  7. ↑ Cancer in Pakistan
  8. ↑ College of Physicians and Surgeons Pakistan Journal, Editorial 2007 http://www.cpsp.edu.pk/jcpsp/ARCHIEVE/JCPSP-2007/dec07/Editorial1.pdf
  9. ↑ "Fighting malnutrition in Pakistan with a helping hand from children abroad". UNICEF. Retrieved 2018-02-21.
  10. ↑ "Pakistan | Hunger Relief in Asia | Action Against Hunger". www.actionagainsthunger.org. Retrieved 2018-03-14.
  11. ↑ "Nutrition country profiles: Pakistan summary". www.fao.org. Retrieved 2018-03-14.
  12. ↑ "Malnutrition in Pakistan severest in region: report". www.thenews.com.pk. Retrieved 2018-03-14.
  13. ↑ "UN World Food Programme". Retrieved 2018-03-14.
  14. ↑ Azizullah, Azizullah; Khattak, Muhammad Nasir Khan; Richter, Peter; Häder, Donat-Peter (2011). "Water pollution in Pakistan and its impact on public health — A review". Environment International. 37 (2): 479–497. doi:10.1016/j.envint.2010.10.007. PMID 21087795.
  15. ↑ Yusuf, Suhail (2013-07-01). "More research in diet and nutrition urged at symposium". DAWN.COM. Retrieved 2018-03-14.
  16. ↑ Rashid MU, Zaidi A, Torres D, Sultan F, Benner A, Naqvi B, Shakoori AR, Seidel-Renkert A, Farooq H, Narod S, Amin A, Hamann U (2006). "Prevalence of BRCA1 and BRCA2 mutations in Pakistani breast and ovarian cancer patients". Int J Cancer. 119 (12): 2832–9. doi:10.1002/ijc.22269. PMID 16998791.
  17. ↑ Pakistan has highest incidence of breast cancer in Asia
  18. 1 2 3 4 Ansari, Inamullah. "Mental Health Pakistan: Optimizing Brains" (PDF). International Journal of Emergency Mental Health and Human Resilience. 17 (1): 288. ISSN 1522-4821.
  19. 1 2 3 Bashir, Aliya (June 1, 2018). "The state of mental health care in Pakistan". The Lancet. Psychiatry. 5 (6): P471.
  20. 1 2 3 Amina, Tareen (1 August 2016). "The mental health law in Pakistan". BJPsych International. 13 (3): 67–69. PMC 5618880. PMID 29093907.
  21. 1 2 3 4 5 6 "WHO Mental health Atlas country profile 2014" (PDF).
  22. ↑ "Schizophrenia not a mental illness, Pakistan's Supreme Court says". 21 October 2016.
  23. ↑ "Ignoring Mental Illness is Among Pakistan's Misplaced Priorities".
  24. ↑ Muhammad Gadit, Amin A. "Is there a visible mental health policy in Pakistan?". Journal of Pakistan Medical Association.
  25. 1 2 Routledge Handbook of Psychiatry in Asia.
  26. ↑ "50 million people with mental disorders in Pakistan'". 9 October 2016.
  27. ↑ "WHO Report on mental health system in Pakistan" (PDF).
  28. 1 2 3 Khalily, Muhammad Tahir (2011). "Mental health problems in Pakistani society as a consequence of violence and trauma: a case for better integration of care". Int J Integr Care. 11: e128. PMC 3225239. PMID 22128277.
  29. ↑ Rahman, A. (15 December 2003). "Mothers' mental health and infant growth: a case control study from Rawalpindi, Pakistan". Child: Care, Health and Development. 30 (1): 21–27. doi:10.1111/j.1365-2214.2004.00382.x.
  30. 1 2 "World Health Day promoting mental health in global development agenda". 8 September 2018.
  31. 1 2 "Pakistan's mental health problem". 7 October 2015.
  32. ↑ Hussain, Syed S. "Integration of mental health into primary healthcare" (PDF). EMHJ. 24.
  33. ↑ S., Karim (2004). "Pakistan mental health country profile". Int Rev Psychiatry. 16 (1–2): 83–92. doi:10.1080/09540260310001635131. PMID 15276941.
  34. ↑ "Basic Needs".
  35. ↑ http://southasia.oneworld.net/todaysheadlines/healthcare-in-pakistan-too-expensive-to-afford
  36. ↑ US should apologise to Pakistan, NATO pay reparations to soldiers: Congressman Kucinich
  37. ↑ IMGs by Country of Origin
  38. ↑ Foreign-trained dentists licensed in the United States Retrieved 08-07-2011
  39. ↑ "Health facts". Ministry of Health, Pakistan. Retrieved 7 September 2010.
  40. ↑ History of Nursing in Pakistan search at Google. Accessed December 10, 2009.
  41. ↑ "Nursing in Pakistan" search at Google. Accessed December 10, 2009.
  42. ↑ "Nursing in Pakistan" search at Google Scholar. Accessed December 10, 2009.
  43. ↑ "Press Information Department". Government of Pakistan. Retrieved 2009-12-12.
  44. ↑ National Programme for Family Planning & Primary Health Care (LHW Programme, MOH Pakistan)
  45. ↑ "MyDoctor.pk raises $1.1 million in funding from Glowfish Capital". Business Recorder. 28 February 2018. Retrieved 24 March 2018.
  46. ↑ "MyDoctor.pk raises $1.1million funding, rebrands to oladoc.com". Pakistan Today. February 21, 2018. Retrieved 24 March 2018.
  47. ↑ "Sehat Kahani, a startup aiming to empower female doctors across Pakistan, raises $500,000 in seed funding". Dawn. March 24, 2018. Retrieved 24 March 2018.
  48. ↑ "Find doctors with mobile app 'Marham' in Pakistan". The News International. October 3, 2016. Retrieved 24 March 2018.
  49. ↑ Javed, Saad Ahmed; Liu, Sifeng (2018-10-08). "Evaluation of outpatient satisfaction and service quality of Pakistani healthcare projects". Grey Systems: Theory and Application. 8 (4): 462–480. doi:10.1108/gs-04-2018-0018. ISSN 2043-9377.
  50. ↑ Javed, Saad Ahmed; Liu, Sifeng; Mahmoudi, Amin; Nawaz, Muhammad (2018-08-30). "Patients' satisfaction and public and private sectors' health care service quality in Pakistan: Application of grey decision analysis approaches". The International Journal of Health Planning and Management. doi:10.1002/hpm.2629. ISSN 0749-6753.

Further reading

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