Research Paper Jill Suzanne Kornetsky 26 October 2010Pakistan and Health: An Overview

Introduction to Pakistan

Pakistan, or “Land of the Pure” in Urdu and ancient Persian1, is a

country in South Asia with shoreline on the Arabian Sea, lying to the

northwest of India and to the east of Afghanistan and Iran; to the north lies

a small portion of a border with China. Current political tensions include

longstanding tensions with India (and their rival development of nuclear

programs), influx of refugees from Afghanistan due to both the current ‘war

on terror’ being waged there and the previous Afghani-Soviet war, tensions in

the Kashmir region where an ongoing debate between sovereignty or separate

possession of the territory by India and/or Pakistan often leads to violence,

and most importantly for the case of this paper, longstanding deficiencies in

development and continued widespread poverty in the country as well as the

region.

The majority Muslim (95%) population in Pakistan numbers 174.5 million

as of 2010, up from an estimated 126 million in 1994 with 36.7% of the

population aged under 15 years as opposed to more than 50% in 1991, a

reflection of increases in basic health statistics leading to greater

longevity, and reductions in birth rates due to greater family planning and

access to contraception (now standing at about 30%). Ethnic groups, also

1 http://www.uh.edu/~sriaz/pakistan/ and http://www.britannica.com/EBchecked/topic/15250/Choudhry-Rahmat-Ali

Page 1 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010linked to language groups used as identifiers within society include

approximately 45% Punjabi, 15% Pashtun, 14% Sindhi, and a number of

ethnic/linguistic minorities at less than 10% of the population each. The

national language is Urdu, with a de facto national language of English for

greater access of the population to higher education in Britain, the US, and

Australia. Punjabi is spoken by nearly 50% of the population, as it is an

ancient language native to the territory, additionally, the variations in

local linguistics mean that residents of areas within Pakistan, particularly

in rural, agrarian communities not prone to frequent the major population

centers often cannot understand one another. 2

Politically, Pakistan has gone through several major transitions,

based on the leadership at the time; since independence in 1947, there have

been alternating periods of democratic and military rule. At present, the

military of Pakistan is the seventh largest in the world, and is active on

many fronts, including the international ‘war on terror’ as well as being a

major contributor to various operations on behalf of the UN. Modern day

Pakistan consists of what was known at the time of independence as West

Pakistan, while former East Pakistan became the independent nation of

Bangladesh in 19713. Since 2008, the semi-presidential government of

Pakistan has been led by President Asif Alu Zardari, who is in the process of

transitioning his nation to parliamentary democracy, which will officially 2 These paragraphs synthesized with material from Blood (1994), the CIA World Factbook (2010), Library of Congress (2005)3 Country Studies: Bangladesh (2007) US Library of Congress

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Research Paper Jill Suzanne Kornetsky 26 October 2010turn his own office into a ceremonial head of state, with the parliament

under the leadership of the Prime Minister retaining “authoritarian and

executive powers.” The transition to democracy has been difficult,

especially since the late 1980’s when power changed hands multiple times due

to allegations of corruption forcing leaders Benazir Bhutto and Nawaz Sharif

alternatively into office and exile multiple times, followed by a period of

military rule. 4 It is anyone’s guess how the government in Pakistan will

eventually be run, a factor which could have far-reaching effects on the

lives of its citizens. Despite the uncertainty of leadership at the highest

levels, over 40 Ministries5 continue to work on essential issues of

development, education, economic growth, health and more.

In 1991, there were 111 males to every 100 females, which was seen to

reflect “the secondary status of females in Pakistani society, especially

their lack of access to quality medical care,” though recent advances in the

availability of medical facilities and access to quality medical care has

brought that figure closer to 106/1006. Major divisions within society

relevant to health indexes now lie between urban and rural populations, as

these two groups differ in their access to education and health services,

clean water and sanitation, immunization coverage of newborns, and subsequent

4 Wikipedia (2010). It is unclear, however, whether proposed evolution of the government will result in actual democratic governance for the country, given the power of the individuals and political parties involved.5 List available at http://www.pakistan.gov.pk/ 6 Blood (1994), the CIA World Factbook (2010) and Library of Congress (2005), plus Federal Bureau of Statistics (2005) and WHO Pakistan Health Profile (2008). Quote from Blood (1994).

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Research Paper Jill Suzanne Kornetsky 26 October 2010disparities in under-5 and infant mortality rates, birth rates, literacy

rates, attended birth rates, immunization, family planning, and other

essential markers of health7. The government of Pakistan, particularly the

Ministry of Health and associated programs, is taking measures to correct

these discrepancies, however the diversion of attention and resources to

basic humanitarian needs in the wake of the recent emergency situation

resulting from extensive flooding throughout the country8 will likely delay

full integration of the rural population into the healthcare system for some

time.

Health in Perspective9

The estimated 2010-2011 governmental budget for the Islamic Republic of

Pakistan is just under 2 Trillion Rs, or around $23B. The percentage of a

national budget that is spent on various services for the population can be

seen as a measure of the importance a government places on those amenities.

Of course, this issue is clouded to some degree by external forces, such as

Structural Adjustment Programs mandated by foreign and multinational lenders.

Rs (millions)USD

(millions)

ClassificationBudget2009-10

Revised2009-10 %

Budget2010-11

Budget2010-11 %

General Public Services 1189081 147174372.96 1387664 16147

69.46

7 WHO. (2008). Pakistan Health Profile8 UN OHCA (2010). Revised 9 Figures for Budgetary Estimates 2010-2011 are taken from the Budget in Brief (5 June 2010), and are converted from Pakistani Rupees into US Dollars, using http://coinmill.com/PKR_USD.html as of 25 Oct 2010.

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Research Paper Jill Suzanne Kornetsky 26 October 2010Defense Affairs &

Services 342913 37813518.75 442173 5145

22.13

Public Order & SafetyAffairs 34641 37385

1.85 51263 596

2.57

Economic Affairs 84926 806084.00 66897 778

3.35

Environment Protection 415 4150.02 448 5

0.02

Housing & CommunityAmenities 1522 1801

0.09 1842 21

0.09

Health Affairs &Services 6484 6743

0.33 7283 85

0.36

Recreational, Culture &Religion 3697 4506

0.22 4359 51

0.22

Education Affairs &Services 31569 31535

1.56 34500 401

1.73

Social Protection 3944 43840.22 1463 17

0.07

TOTAL: 1699193 2017255 100 1997892 23247 100Table 1: Budget Estimates for the Islamic Republic of Pakistan. Taken from Table 15 of the

Budget in Brief (2010)

When comparing the relative expenditures of Pakistan, the US, and the UK

(as seen in Appendices A and B), there are some obvious trends in national

budgeting for essential services. It is important to note that the United

States has not yet implemented the planned Universal Healthcare package, the

UK has a National Health Services System to provide for its population, and

that the government of Pakistan is in the process of implementing national

primary care services to all of its population (but has not yet reached full

saturation, nor does this coverage necessarily provide for all needed health

services). In 2010, Pakistan has dedicated only 0.36% of its annual budget

to Health Affairs and Services, which is up only 0.03% from the previous

fiscal year. Comparatively, the US planned for just under 7% of its total

Page 5 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010discretionary budget to Health and Human Services, while the UK devoted 30%

of its total spending to the National Health Service.

The largest percentage of Pakistan’s budget (70%) dedicated to the

somewhat ambiguously titled “General Public Services.” As listed in Table

16 of the Budget in Brief 2010, these funds are divided between executive and

legislative financial obligations, general services, and research. Looking

more closely at the figures we see that servicing of foreign debts makes up a

majority of this budget; 48% of this budget, totaling 577B Rs or $6.7B goes

in some form towards foreign debts. This means that more than one quarter of

Pakistan’s budget is leaving the country this year to pay off foreign loans,

funds that could be serving the people of Pakistan by contributing to greater

investments in health, infrastructure, education, and other basic human

needs.

Additional expense discrepancies to note include 22% of the budget for

defense compared to less than 2% for education and 2/100ths of a percent in

environmental provisions. Given the focus of much of Pakistani GDP on the

agricultural sector, it would be prudent for a reassessment of the

government’s focus on protecting the natural environment, while attention to

educating the population would provide greater economic opportunities in the

future by expanding the potential for higher-earning industries. By

comparison the US spends about 4%, and the UK over 15% of their annual

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Research Paper Jill Suzanne Kornetsky 26 October 2010budgets on education, and each will spend about 1% on the environment in

2010-2011; the UK has a line item for Energy and Climate Change specifically.

The World Health Organization estimates that total expenditures on

health (THE) in Pakistan, as a percentage of the country’s GDP, was 2.9% in

2008, down from a high of 3.7% in 1999. Of these costs, private expenditures

on health (PvtHE) made up 70.3% of the THE in 2008, down slightly from 80.9%

in 1999. Of these payments towards health, out-of-pocket expenditures on

PvtHE have remained at or around 80% for at least the last 15 years10. For a

country estimated to have 24% of its population living below the poverty

line,11 31-38% of children under 5 moderately to severely underweight, and 42%

of children under 5 moderately to severely stunted in growth12, the notion

that the average Pakistani, especially in rural settings where poverty is

more pronounced13, “in 1992 some 35 million Pakistanis, or about 30 percent of

the population, were unable to afford nutritionally adequate food or to

afford any nonfood items at all,”14 would be able to afford non-food

expenditures such as out-of-pocket healthcare is simply farfetched.

Clearly, Pakistan has some ground to cover in the socially just

allocation of its national budget if it is going to compete with the UK or

10 WHO. (2010). National Health Accounts11 CIA (2010). Pakistan: World Fact Book online (2005-6 statistic)12 UNICEF (2010). Pakistan: Statistics13 Akhtar, S. (2008). Trends in Regional Inequalities in Pakistan.14 Blood. (1994) Pakistan – Health and Welfare

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Research Paper Jill Suzanne Kornetsky 26 October 2010even the US15 on the grounds of Health, Education, and Environment. Even to

produce a nationwide minimal standard of care and health will require a great

deal of effort and careful reallocation of funds. Reducing Pakistan’s

military spending is unlikely, given the number of conflicts they are working

against within their borders, and potentially unwise, given the reliance of

the UN on Pakistan for its own military operations as well as the cooperation

the Pakistani military is giving to the United States in fighting terrorism

locally and globally. Instead it may be prudent, especially in the wake of

the devastation wrought by the 2010 floods (discussed below), for the

international community to forgive Pakistan’s debts and allow a refocusing on

issues relative to domestic growth and development. According to the

Ministry of Health, significant efforts are being undertaken to ensure

fulfillment of the government and constitutional promise of healthcare

availability to the masses16. Hopefully these promises can come to fruition

sooner rather than later.

Structure of the Pakistani Healthcare System

The structure of any healthcare system relies upon several key factors:

facilities, personnel, financing, and the distribution of all three

15 Despite the wealth and high GDP of the US, it is certainly not as socially just or equitable in its resource distribution as some other countries, particularly in termsof such politically contentious subjects as health and education, in my opinion.16 Article 38 of the Constitution, reviewed at http://criticalppp.com/archives/6186

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Research Paper Jill Suzanne Kornetsky 26 October 2010throughout geographic and demographic areas. In Pakistan, a country with a

population of 170 million people17 dispersed over an area approximately twice

the size of California18, efforts are being made to increase the capacity of

the healthcare system, focusing more on addition of personnel rather than on

increasing the number of beds or facilities available. Pakistan is a

signatory nation of the Alma Ata Declaration of 1978; in 1994 a program to

improve basic primary healthcare and increased family planning to control

population growth was launched. While the capacity of the Pakistani

healthcare system is still lacking due to budgetary constraints, the

advancements being made indicate a certain level of attention to making

whatever changes are feasible for the nation. The government is aware of the

need for improvement in the quality and quantity of healthcare. The Ministry

of Health website features several programs focused on communicable diseases

and immunizations, maternal and child health, and nutrition both caloric and

micronutrient focused.

Between 2000 and 2009 the total number of institutions nationwide,

including hospitals, dispensaries, rural health centers, TB clinics, and

other facilities with inpatient capabilities has only increased from 12,343

to 12,897 (4.5% increase) with an increase in available beds from 93,907 to

103,708 (a 10% increase in 9 years). For the given population, this means

one bed for every 1600 people in 2009, and the relatively low increase in 17 Government of Pakistan. (2010). Population Census Organization estimate of population on 25 October 2010.18 CIA (2010). World Factbook online: Pakistan

Page 9 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010healthcare infrastructure is likely the result of the Low Income status of

Pakistan. The number of healthcare workers, however, has increased more

substantially; over the same nine year period (2000-2009) there has been a

16% increase in the number of midwives (22525 to 26225), a 50% increase in

the number of physicians (92863 to 139555), an 84% increase in the number of

nurses (37528 to 69313), a 97% increase in the number of “Lady Health

Visitors” or Workers (from 5443 to 10731), and a 135% increase in the number

of dentists (4165 to 9822) working across the country. The notion of a Lady

Health Worker (LHW) is part of Pakistan’s efforts to increase baseline

statistics of health such as vaccination, nutrition, and family planning

interventions essential for a country with a large and growing population.

Part of the National Programme for Family Planning and Primary Healthcare:

“LHW acts as a bridge between the care provider of formal health system and the community. They are providing promotive, preventive and curativeservices to their communities in the field of health education, maternaland child health, nutrition, family planning and treatment of minor ailments. They are also involved in national level health related activities like Polio NIDs, Maternal and Neonatal Tetanus elimination activity, EPI vaccination, DOTS therapy, nutrition activities and AFP surveillance. Their specific objectives are reduction of IMR, MMR, and increase in CPR, Immunization coverage, early initiation of breast feeding and deliveries by skilled birth attendants.

The LHWs after recruitment are trained for fifteen months at FLCF and are then based in their own locality. Their home is designated as a Health House. Health Facility in each union council is the focal point of each LHW. The Facility Medical officer, LHV and Health Technician actas their trainers for their basic and 15 days Refresher training every year . LHWs submit their monthly MIS report on 1st of each month during their one day continued education session and get their monthly quota of

Page 10 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010medicine and Family Planning items (condoms & oral pills).Their monthly stipend is Rs.2990/pm.”19

Statistics taken by the Oxford Policy Management UK group have associated the

LHW program with various measures of progress in primary and maternal

healthcare. The most significant improvement seems to be a shift in the

Maternal Mortality Ratio, from 340 nationwide to 180 in communities with

LHWs; a similar improvement in the Infant Mortality Ratio is noted, from 77.9

nationally to 50 in LHW communities. For just under $35 per month, the LHW

lives and works in her home community, improving the survivability of

childbearing and educating the local women about birth control, vaccinations

for their children, and nutrition – all essential first steps in establishing

a healthier country. Continued incremental progress in healthcare capacity,

through such program as “national health planning [that] began with the

Second Five-Year Plan (1960-1965) and continued through the Eighth Five-Year

Plan (1993-1998),”20 as well as a focus of more national monies on healthcare,

should go a long way in improving basic health statistics in Pakistan.

Quantification of Health

Healthcare statistics are a useful and universal way of estimating the

state of health within a population; “accurate information is the lifeblood 19 20 Blood (1994). Pakistan – Health and Welfare

Page 11 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010of decision making, and the current proliferation of health programs means

the demand for reliable data is greater than ever.” Through initiatives at

the Ministry of Health as well as at the Ministry of Economic Affairs and

Statistics, Pakistan demonstrates a relatively high level of monitoring of

many vital health statistics as compared to many low-income countries. While

one must exercise caution in taking health statistics to be entirely

accurate, should “always be cautious in interpreting health-related data, as

it is difficult to define the metrics, hard to get the numbers right, and

there may be pressure on local and regional officials and ministries of

health to distort figures,”21 the wealth of data from multiple sources within

Pakistan as well as from international bodies such as the WHO implies that

these data are both thorough and reliable. For example, data is provided on

the WHO website for rates of immunization coverage between 1980 and 2009 both

from Pakistani and WHO sources. Since 2002, these numbers have been

identical for both groups, with one exception – Pakistan seems to be

underreporting rates of Tetanus vaccination as compared to WHO results. For

at least the last eight years, it appears that the statistics for vaccination

rates, at least, are reliable and honest.22

Pakistan has made significant advancement in reducing the incidence of

vaccine-preventable diseases. Data from the WHO includes surveillance of

Diphtheria, Measles, Pertussis, Polio, and Tetanus yearly from 1980 to 21 Quotes from Birn et al. (2009) Textbook of International Health. pp192, 19822 http://apps.who.int/immunization_monitoring/en/globalsummary/countryprofileresult.cfm

Page 12 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010present day. Rather than list these data in prose format, Graphs 1 and 2

provide an illustration of these data, and shows the dramatic decreases in

these diseases with the advent of national vaccination programs such as the

Expanded Program on Immunization. “A network of immunization clinics –

virtually free in most places -- exists in urban areas and ensures that

health workers are notified of a child’s birth [so that they might be

immunized]. Word of mouth and media attention, coupled with rural health

clinics, seem to be responsible for the rapid increase in immunization rates

in rural areas.23”

23 http://202.83.164.26/wps/portal/Moh and Blood (1994) Pakistan – Health and Welfare:Maternal and Child Health

Page 13 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010

0

10000

20000

30000

40000

50000

60000

Diphtheria Measles Pertussis

Incidence Rate (# of Cases) for Pakistan 1981-2009

010002000300040005000600070008000

Polio  * Tetanus (neonatal) Tetanus (total)

Incidence Rate (# of Cases) for Pakistan 1981-2009

Graphs One and Two: Adapted from WHO 2010 Global Summary Vaccine-Preventable Disease

Given the successes of the EPI on reducing vaccine-preventable disease,

it is no surprise that the government provides plenty of data on the subject.

There are other health statistics where Pakistan still lags behind in its

progress, and accordingly, these statistics are slightly harder to find.

With a little hunting, however, national statistics can be found within some

of the larger reports cosponsored by agencies such as USAID, or independent

overviews by the WHO, and they are encouraging with regards to the progress

Page 14 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010made since the early 1990s. Of these statistics, the most salient are those

which are used internationally as indicators of the overall state of health

for a population. “Two categories of mortality rates are of particular

significance for international health: the infant mortality rate (IMR) and

maternal mortality.24” The WHO’s Global Health Observatory has tracked some

vital statistics in Pakistan since 1990. The following Table 2 lists several

key indicators or contributors to health at 5-year intervals with the latest

available data from the WHO in 2008.

1990 1995 2000 2005 2008IMR 101 94 85 76 72

MMRatio (per 100,000 live births)490[260-960]

410[220-790]

340[180-650]

290[160-550]

260[140-490]

Under-5 Mortality Rate 130 121 108 96 89Gross National Income ($ per

capita) 1260 1520 1690 2230 2590

% of Population with ImprovedWater 86 87 88 89 90

% of Population with ImprovedSanitation 28 33 37 41 45

Total Fertility Rate (per woman) 6.1 4.7 4Table 2: Adapted from WHO (2010) Global Health Observatory: Pakistan

From the data, we can see that mortality statistics have been in steady

decline since 1990 in Pakistan. This corresponds with increases in per

capita income, availability of improve water and sanitation, access to

immunization resources (as listed above in Graphs 1 and 2) and a decrease in

the total fertility rate - all marks of a society moving towards

modernization and improved standards of health.

24 Birn (2009) p215Page 15 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010Other health statistics as listed in the same WHO document, with slight

improvements, have remained alarmingly high in Pakistan. These include rates

of malnourishment as indicated by the percentage of children under 5 stunted

for their age (41.5% in 2001 down from 54.5% in 1991) and underweight for

their age (31.3% in 2001 down from 39% in 1991). Additional information from

the WHO indicates that in 2005-2006, 32% of babies were born underweight, and

in 2001, 14% of children under % exhibited signs of wasting. Further

indicators of malnourishment are that in 2005, 22.6% of the population was

living on less than $1 per day, and in 2006 23% of the population was

consuming less than the minimum level of dietary energy consumption, and in

2004 the Human Development Index ranking for Pakistan was 135 out of 177

countries.25 The National Nutrition Program has been instituted by the

Ministry of Health to address this:

“Malnutrition is one of the major public health problems in Pakistan. Malnutrition occurs throughout the lifecycle resulting in low birth weight, wasting and stunting. National Nutritional Survey 2001-2002 shows the alarming situation of Pakistan. Micronutrient deficiency in Pakistan is widespread and reflects a combination of dietary deficiency,poor maternal health and nutrition, high burden of morbidity and low micronutrient content of the soil especially for iodine and zinc. Most of these micronutrients have profound effects on immunity, growth and mental development and may underlie the high burden of morbidity and mortality among women and children in Pakistan.26”

The aggregation of this data indicates that along with healthcare, health

facilities, health practitioners, water and sanitation improvements, and

25 WHO (2008) Pakistan: Health Profile26 From Government of Pakistan. (2010). Homepage. Ministry of Health: National Nutrition Program

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Research Paper Jill Suzanne Kornetsky 26 October 2010direct biomedical interventions for health, Pakistan needs to invest in food

security and the National Nutrition Program if the population is to see

significant improvements in health.

The epidemiological profile for Pakistan27 is experiencing the shift

towards non-communicable diseases (NCDs) that is typical of a low-income

country that remains poor while also experiencing the health burden of

modernization and urbanization with all of the accompanying problems:

urbanization in crowded, unsanitary housing where communicable diseases

continue to spread, respiratory problems both infectious and environmental,

stress-induced non-communicable illnesses such as heart disease, and cancer.

As of 2004, NCDs accounted for 45.9% of mortality in males, and 44.8% of

mortality in females; these represent significant shifts from even the 2002

statistics, where NCDs accounted for 40.3% and 38.5% of mortality in males

and females, respectively. A large part of this shift may be due to the

decrease in disease burden for infectious diseases preventable by

vaccination. Still, the Pakistani Ministry of Health maintains programs in

Malaria, TB, and AIDS control, indicative of the resilience of these diseases

to intervention strategies, educational programs and in the case of TB, the

expense of DOTS therapeutic intervention.

Factors Affecting Health

27 See Appendices C and D: Proportional Mortality for Males and Females, 2004 and 2002Page 17 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010The WHO Health Profile (2008) for Pakistan indicates significant

disparities in the facilities relating to, and outcomes in health between

urban and rural populations. Where listed, the comparisons between the

wealthiest 20% of the population and the poorest 20% are even more disparate.

These inequities are an indication of the level of deprivation and

marginalization rife in Pakistani society. Sanitation facilities were

available to approximately 75% of the urban population in 2008 and have been

since 1990, according to this document, while only about 30% of rural

individuals have the same facilities; this represents an improvement since

1990, when less than 10% of the rural population had improved sanitation.

Health services utilization shows greater inequities, with 30% of rural birth

being attended as compared to 60% in urban settings; 77% of wealthy births

were attended compared to only 16% of the poorest mothers indicating a likely

correlation with the availability of healthcare provisions for the poor.

Measles immunization showed a similar pattern with 56%/69%, rural/urban,

compared to 36%/76%, poorest/richest quintile. Child mortality for the poor

was more than double that of the wealthy, with under-5 mortality at 121

versus 60 in 2008.

In a report from the National Institute of Population Studies (NIPS),

“Pakistan: Demographic and Health Survey 2006-2007,” a lack of health

education, and education for women in general, seems to be an underlying

Page 18 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010factor for many health disparities28. One measure of this lack of education

is in the adult literacy rate. In 2005, the literacy rate for Pakistan was

49.9%, with 63% of males and 36% of females over the age of 15 being

literate29. Nearly 50% of the rural population has never been to school

compared with 26% in urban settings, while 70% of the poorest quintile and

16% of the highest wealth quintile have no education.

In particular, only 4 out of 10 women have a basic knowledge about HIV

and how it is contracted, only 55% of women use exclusive breastfeeding in

the first six months after birth (with a high percentage of mothers feeding

infants under two months water (13%), non-breast milk (43%), sugar or honey

water (25%), ghee (10%) and green tea (17%) and other substitutes

contraindicated by the recommendation of exclusive breastfeeding), 34% of

mothers reduce fluids to a child with diarrhea which puts those children at

risk of serious complications or death, and nationally only 6% of households

have a mosquito net, a factor which contributes to the high malaria rates

within the country. Each of these barriers to health can be addressed with

an education campaign that would ultimately save lives30.

Additional factors related to the overall health status in Pakistan are

relative to the political economic analysis of health and development, which

28 Indeed, the CIA World Factbook (2010) indicates that Pakistan is ranked 153/177 in national education expenditures29 CIA World Factbook (2010)30 Information synthesized from the National Institute of Population Studies 2006-2007document.

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Research Paper Jill Suzanne Kornetsky 26 October 2010“considers the political, social, cultural, and economic contexts in which

disease and illness arise… the ways in which the societal structures (i.e.

political and economic practices and institutions, and class interrelations)

interact with the particular conditions that lead to good or ill health…[as]

health problems can only be addressed beyond the behavioral or medical

levels, through improved working conditions, social policies, and political

mobilization.31” As one of the lowest income countries on earth (173/177 in

GDP per capita32), with ongoing gender inequality, child labor, hazardous

working and living conditions, inadequate investments in health and

education, human trafficking, famine conditions, environmental impacts

including a 2005 earthquake and the 2010 emergency-level flooding, a refugee

population resulting from the current ‘war on terror’ as well as leftover

refugee populations from the Soviet-Afghani War, as well as large proportions

of annual federal budgets dedicated for payments to service national debt,

Pakistan is in a poor position to improve its various indexes of health and

development.

Frameworks of Prevention: Malaria and Cancer

The frameworks of prevention33 seek to control disease and associate

morbidity and mortality by working on three levels: primary, secondary, and

31 Birn (2009) p13432 CIA World Factbook (2010)33 Birn (2009). p 250

Page 20 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010tertiary prevention. Two of the more pressing health conditions in Pakistan

today are Malaria and Cancer. According to the Directorate of Malaria

Control in Islamabad, “Malaria is the 2nd most prevalent and devastating

disease in the country. The Government of Pakistan has established the

directorate for early diagnosis and prompt treatment, multiple prevention,

improved detection and response to epidemics, developing viable partnerships

with national and international partners, and focused operational research.34

According to the WHO Country Office in Pakistan, of NCDs, “prevention and

control of important types of cancer” is listed as the first objective for

the office, with breast (15%) and lung/stomach/esophagus/bronchus cancers

(8/7/6/5%, or a total of 26%) being some of the most prevalent35.

In the program to control Malaria, primary prevention, or actions “taken

to prevent infection or exposure, avoid development of the disease, and

promote overall good health36” would include education on how the disease

spreads and how to prevent it, or “effective behavior change communication”,

distribution and diligent usage of mosquito nets (especially those treated

with an insecticide such as pyrethrin) when sleeping, wearing long sleeves

and pants and using insect repellent if outside at night, controlling the

mosquito population by eliminating sources of uncovered standing water and/or

the use of larvicides, and other environmental measures of control. The

National Malaria Control Programme has identified many of these strategies in34 From Government of Pakistan. (2010). Homepage. Ministry of Health.35 http://www.emro.who.int/pakistan/programmes_ncd.htm 36 Birn (2009). p 250

Page 21 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010its Roll Back Malaria in Pakistan37 program, and will pursue its specified

measures using a $23M grant obtained from the Global Fund for AIDS,

Tuberculosis and Malaria (GFATM).

Secondary prevention or “activities aimed at early detection of the

disease to prevent its development” as well as tertiary prevention, “similar

to disease management, attempts to mitigate the negative effects of any

complications or disability arising from an illness once a person is

diagnosed38” are handled in a two-step approach outlined by the Ministry of

Health’s Programme. This includes both “early diagnosis and rapid treatment”

using an Atemisnin-based Combination Therapy or ACT according to the WHO’s

direction, as quinine-based therapies and mono-drug therapies are no longer

effective against P. falciparum in the region. Any patient experiencing an

unexplained fever is encouraged to seek out a testing center to undergo

confirmation of Malaria using a blood smear and immediate ACT dosing. ACT

consists of both Artesunate and Sulfadoxine-pyrimethamine which will be

“freely available at all malaria diagnosis and treatment centers in the

target districts during the life of the current [GFATM] proposal, and will be

sustained by the district, provincial and federal government after completion

of the project.” 39

37 Government of Pakistan: Ministry of Health Homepage: National Malaria Control Programme38 Birn (2009). p 25039 Government of Pakistan: Ministry of Health Homepage: National Malaria Control Programme

Page 22 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010Breast cancer is a growing health problem in Pakistan40, (it is cited as

having the highest breast cancer incidence in Asia) as are the multiple

cancers associated with the use of tobacco including chewing tobacco and

smoking cigarettes. Primary prevention for breast cancer is a tricky topic,

as up to 20% of breast cancers are genetic – something that is expensive to

screen for in an already impoverished country; primary prevention for

tobacco-associated cancers has a more straightforward approach – smoking

cessation and tobacco education. In both cases, as for all types of cancer,

any attempt to live a healthier lifestyle, eat more nutritious foods, and get

both sufficient rest and exercise pay help prevent the incidence of cancer.

Secondary prevention for cancer involves screening patients at-risk

using simple hematology (which can indicate the presence of cancer early by

the detection of abnormal cells or high WBC counts), chest x-ray screening

for smokers or former smokers who have additional risk factors such as

exposure to asbestos or other carcinogenic materials, and education of women

on the need for self-examination as well as regular and routine checkups with

their physician for annual examinations. According to the news article

footnoted, Larkana Institute of Nuclear Atomic Radiotherapy (LINAR) will be

offering mammography services for even earlier detection of potential breast

cancers. Detection of any cancer would ideally be treated through a

combination of radiation, chemotherapy, and/or surgery to remove the 40 No pun intended. See news articles at http://www.pakistanchristianpost.com/headlinenewsd.php?hnewsid=2356 and http://www.thenews.com.pk/latest-news/3480.htm

Page 23 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010neoplasm. Tertiary prevention for cancers would be palliative care for

patients with cancer too advanced for remission by secondary prevention

(treatment). It would also involve reconstruction and rehabilitation

services for those patients having undergone the rigors of cancer therapies

as well as supportive care during the treatment phase of their care plans.

The availability of screening and treatment in Pakistan is in some question,

as these therapies are costly, and require access to advanced medical

apparatus and surgical facilities which are likely to be found only at the

larger medical centers within the country.

Global Implications of a National Health Issue: HIV

According to a recent report produced by the WHO in cooperation with

UNAIDS and UNICEF41, HIV is growing in prevalence in Pakistan. While

injection drug users are believed to make up the majority of those infected,

and there is reluctance by the government to admit that HIV might be a

growing or continuing problem in Pakistan42, increasing numbers of infections

have been recorded in the report. The prevalence is especially problematic

in populations of migrant men, such as truckers, who have the potential to

41 Epidemiological Fact Sheet on HIV and AIDS: Pakistan (2008). 42 http://www.nation.com.pk/pakistan-news-newspaper-daily-english-online/Regional/Islamabad/30-Jul-2009/AIDS-project-for-truckers-hits-snags and http://www.fhi.org/en/CountryProfiles/Pakistan/res_PakistanTruckersProject.htm

Page 24 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010contract the disease and spread it along their travel routes, should they

engage in unprotected sex with multiple partners along the way.

With the increased frequency and speed of travel between geographic

areas that accompanies globalization, HIV has proven itself capable of

spreading rapidly within and between populations. Pakistan abuts four

countries, and acts as a conduit for trade between them. The potential for

these truckers and other migrant workers to mix with trade workers, refugees,

migrants, and other populations in the various states and territories within

and beyond Pakistan gives this problem a global implication on adverse health

outcomes – more so than other STIs, as there is yet no cure for HIV, and the

cost of treatment to reduce viral load and keep patients healthy is high. A

strong and continued response including education about the risks and means

of transmission of HIV, a concerted effort to end stigma and discrimination,

education and empowerment of sex workers along trucking routes, information

and provision of means allowing individuals to protect themselves and their

future partners through use of condoms and water-based lubricants, and

increased availability of voluntary counseling and testing services in

convenient locations will all help limit the effects of this emerging

problem.

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Research Paper Jill Suzanne Kornetsky 26 October 2010Extrapolating a Successful Program: Controlling Mother-to-Child HIV

Transmission

While general approaches to educating the public, offering testing and

counseling services, and using mass media to reduce stigma and ignorance have

been employed43 one area which is not being addressed sufficiently44 that has

had extremely high success rates in other countries is the use of

Antiretroviral Drugs(ARVs), especially by pregnant HIV-positive women to

prevent mother-to-child transmission of the virus. According to the report,

zero mothers have been given ARVs in order to protect their children from

contracting their mothers’ virus. Commonly understood estimates for the

success rate in these settings is a reduction is a 95% chance of the newborn

avoiding contraction of HIV if the mother uses ARVs responsibly during her

pregnancy.

In 2007 there were an estimated 2300 HIV-positive women carrying

children, and yet none of them were being treated. It is unclear whether the

problem is a lack of adequate testing and treatment facilities, a lack of

adequate pre-, ante-, and post-natal care, a lack of education, or social

bias leading to the denial of HIV status (or a combination thereof) is at the

root of this oversight. The medical successes in preventing mother-to-child

transmission of HIV using ARVs, however, should outweigh the potential stigma

43 Indicated by the level of knowledge in Pakistani men: http://www.popcouncil.org/pdfs/Pak_STIsStudyReport.pdf 44 An estimated 600 people received ARVs in 2007, with an estimated 20,000 needing them.

Page 26 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010and expense given the implication of confidentiality between doctor and

patient, the investments in HIV interventions in Pakistan by national and

international actors, and the commitment of the Ministry of Health to its own

National AIDS Control Programme. Implementation of this health intervention

should be easily integrated into the network of medical facilities already

existing in Pakistan, and would be facilitated by increased education (mass

media or direct local campaigns) and encouragement of voluntary testing and

counseling services.

Conclusion

As has been illustrated in the many statistics and references provided

in this paper, Pakistan is a low income country facing a myriad of health

problems today and in the years to come. Major barriers to overcoming those

issues include sufficient availability of the facilities, practitioners and

funding for health interventions including primary and health education,

vaccination campaigns, birth control and means of prophylaxis to prevent

against STIs, increased primary healthcare, improved food security and

nutrition programs and other biomedical and behavioral interventions for

health. More importantly in a country still in the process of establishing

democratic rule and egalitarian access to opportunity will be addressing the

political economic factors interfering with achieving improved outcomes.

Page 27 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010National focus by the government must address the underlying causes of

inequality within Pakistani society –class divisions, gender disparities and

wealth distribution would be some good places to start. Infrastructure and

political will are necessary to achieve better outcomes within rural

populations. Control and modification of the negative consequences of

modernization such as pollution, hazardous work and working conditions,

sweat-shop and child labor, human trafficking, sex work, water and sanitation

for a growing urban population in addition to achieving baseline public works

for rural populations will be key to empowering the workforce and improving

their health. Direct biomedical interventions and systems can improve the

major statistics of health regarding mortality rates.

Perhaps unifying all of the proposed interventions will be accessing a

greater amount of national funds by eliminating foreign debt and whatever

Structural Adjustment Policies accompany it. Neoliberal approaches may allow

a focus on economic growth; however it can easily be argued that whatever

growth Pakistan is experiencing will continue to be unequally accessed by

different geographic populations, making that growth meaningless to the

marginalized. Before true development and growth can happen, systems must be

in place to ensure that economic expansion benefits all members of Pakistani

society.

Page 28 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010Appendix A: US Budget 2009-2011

USD (billions)Discretionary Budget by

Agency Base Budget 2009-2010 % Budget 2010-11 %Agriculture 23.9 2.25 26.0 2.30Commerce 9.3 0.88 13.8 1.22

Defense 513.348.35 533.7 47.11

Education 41.4 3.90 46.7 4.12Health and Human Services 26.4 2.49 78.7 6.95

Homeland Security 80.1 7.55 42.7 3.77Housing and Urban Development 40.1 3.78 47.5 4.19

Interior 11.3 1.06 12.0 1.06Justice 25.5 2.40 23.9 2.11Labor 12.7 1.20 13.3 1.17

State/International Programs 36.7 3.46 51.7 4.56Transportation 70.5 6.64 72.5 6.40

Treasury 12.7 1.20 13.3 1.17Veterans Affairs 47.6 4.48 52.5 4.63Corps of Engineers 5.3 0.50 5.1 0.45

Environmental ProtectionAgency 7.8 0.50 10.5 0.93

General ServicesAdministration 0.7 0.73 0.6 0.05

NASA 17.8 0.07 18.7 1.65National Science Foundation 6.9 1.68 7.0 0.62Small Business Administration 0.7 0.07 0.7 0.06

Social Security 8.8 0.83 9.7 0.86Corp. for National and

Community Service 0.9 0.08 1.1 0.10National Infrastructure Bank 0.0 0.00 5.0 0.44

Other 19.1 1.80 19.8 1.75TOTAL: 1061.6 1132.8

Taken from Table S-7 of the 2010-2011 US Budget “A New Era of Responsibility: RenewingAmerica’s Promise”

Page 29 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010Appendix B: UK Budget 2010-2012

Departmental Program andAdministration Budgets

Pounds Sterling (billions)Baseline2010-11 %

Budget2011-12 %

Education 50.815.55 51.2

15.67

National Health Services 98.730.22 101.5

31.07

Transport 28.58.73 5.3

1.62

Business Innovation and Skills 16.75.11 16.5

5.05

Home Office 9.32.85 8.9

2.72

Justice 8.32.54 8.1

2.48

Law Officers' Departments 0.70.21 0.6

0.18

Defense 24.37.44 24.9

7.62

Foreign and Commonwealth Office 1.40.43 1.5

0.46

International Development 6.31.93 6.7

2.05

Energy and Climate Change 1.20.37 1.5

0.46

Environment, Food and Rural Affairs 2.30.70 2.2

0.67

Culture, Media and Sport 1.40.43 1.4

0.43

Olympics 0.00.00 0.1

0.03

Work and Pensions 6.82.08 7.6

2.33

Scotland 24.87.59 24.8

7.59

Wales 13.34.07 13.3

4.07

Northern Ireland 9.32.85 9.4

2.88

HM Revenue and Customs 3.51.07 3.5

1.07

HM Treasury 0.20.06 0.2

0.06

Cabinet Office 0.30.09 0.4

0.12

Single Intelligence Account 1.7 0.5 1.7 0.5

Page 30 of 37

Research Paper Jill Suzanne Kornetsky 26 October 20102 2

Small and Independent Bodies 1.80.55 1.8

0.55

Reserve 2.00.61 2.3

0.70

Special Reserve 3.41.04 3.2

0.98

TOTAL: 326.6 100 326.7 100Taken from Table 1 of the 2010 Spending Review from Her Majesty’s Treasury

Page 31 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010Appendix C: WHO Global Infobase Mortality for Pakistan 2004

https://apps.who.int/infobase/Mortality.aspx

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Research Paper Jill Suzanne Kornetsky 26 October 2010Appendix C: WHO Global Infobase Mortality for Pakistan 2002

https://apps.who.int/infobase/Mortality.aspx

Page 33 of 37

Research Paper Jill Suzanne Kornetsky 26 October 2010

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