he population of [West] Pakistan at the time of independence was between 30 million and 40 million. According to the 7th Population and Housing Census in 2023, we are now more than 240 million. This is a more than seven-fold increase in 77 years. We have proliferated at a high growth rate – currently 2.5 percent, which is one of the highest in the region. This means every year around six million people are added to the population – almost equal to the entire population of Norway.

While population has grown steadily, the economy has not. For this and other deep and chronic structural issues in our economy, including low and non-inclusive growth, poverty has been on an overall upward trajectory. Recent estimates show that it is again growing and hovers currently around 100 million.

Poverty and disease are close relatives and feed off each other. Hence, “diseases of poverty” are rampant in Pakistan. We are also one of the lowest spenders on health i.e., less than 1 percent of the GDP. The pattern of our spending on health is lopsided. We spend around 70 percent on big hospitals and only 30 percent on primary healthcare where diseases can be prevented.

The Human Development Index has been declining for seven years. We now stand at 164 out of 193 countries. Along with Afghanistan, we have the lowest HDI in the SAARC region. Globally, we are in the company of Nigeria and Rwanda. Low HDI means low human capability. According to the World Bank’s Pakistan Human Capital Review, in 2023, the country’s “human capital outcomes are more comparable to those in sub-Saharan Africa.” Balochistan “is at the global bottom, at the same level as Niger.”

This is what happens when basic human needs are ignored for decades and elite capture on national resources remains tight. The ongoing and deepening public health crises in the country are a part of this tragedy.

We carry a very heavy, and not effectively addressed, burden of disease. Much of it is preventable.

Current life expectancy in Pakistan is 67.7 years. One hundred and forty-nine countries have higher life expectancy than us, including many poor African countries. An average Pakistani’s lifespan is almost 10 years less than a Sri Lankan, nine years less than an Iranian, seven years less than a Chinese and five years less than a Bangladeshi or a Vietnamese. The reason is simple: the state has not prioritised the health of its people.

We have the second highest neonatal mortality rate in the world – out of every 1,000 live births, 40 newborns die within 28 days of life. A shocking 40 percent of children less than five years of age are physically and mentally stunted primarily due to malnutrition. If stunting is not reversed in the first 1,000 days of life, it becomes a life-long tragedy. Around 43 percent of women aged 15-49 have iron-deficiency anaemia. This is a major reason for underweight children born to these mothers and a risk factor for maternal mortality due to post-partum haemorrhage.

Pakistan and Afghanistan are the only two countries in the world where polio has not been eradicated. Pakistan is home to the world’s largest population of people infected by hepatitis C, surpassing even China, India and Nigeria. Pakistan is ranked fifth among countries with a high burden of tuberculosis. After the Philippines, we have the highest rate of increase in the number of HIV cases in Asia – more than 80 percent increase between 2010 and 2020. Every fourth woman in Pakistan undergoes perinatal depression; every fifth school-going child has an emotional or behavioural problem; every third adult above 45 suffers from high blood pressure; and every fourth adult above 20 years has Type II diabetes.

The best indicator of the state’s resolve can be establishing people’s right to health through a constitutional amendment and to increasing the health budget. 

Access to proper nutrition, safe drinking water and clean air are determinants of health. Among environmental determinants of health, as an example, Pakistan has become the fourth most polluted country in the world. Lahore now has the distinction of being the most polluted city on the planet. We are among the top 15 countries in the world with widespread tobacco consumption and higher rates of tobacco-related health issues. According to 2019 estimates, 19.1 percent of the population – around 42 million adults – consume tobacco in one form or the other.

These figures hide serious disparities in health within the country. Just one example, to make the point: around 90 percent of the children in the Punjab and Islamabad receive routine immunisation whereas less than 40 percent children are immunised in Balochistan and less than 20 percent in North Waziristan, Bolan and Pishin.

Can this be fixed? Of course.

First, the state must prioritise people’s health; especially the poor people’s health. The best indicator of the state’s resolve will be establishing people’s right to health through a constitutional amendment and increasing the health budget.

Second, federal and provincial governments should ensure progressive universal health coverage in the country. UHC is only possible through the delivery of predefined essential package of health services at primary healthcare level, which is closest to the people. This will require a paradigm-shift from curative care only to primary care level preventive approach.

Third, as a part of UHC agenda, universalisation of healthcare has to begin where it is most needed. Rural areas should be a priority. The poor, children, women, the transgender community, elderly and other vulnerable populations must be a priority. As the economic situation improves, the healthcare net should be expanded to wider populations and with more health services. The Sehat Sahulat programme has to be limited to only those who cannot pay or are categorised as vulnerable. It has to be introduced among GPs in the private sector so that impoverishing expenditures on health can be addressed.

Fourth, an aggressive programme for family planning must be launched for free availability of low-cost family planning services across the country.

Fifth, wide-ranging health system reforms and alignment with the goals of UHC have to be done so that there is a cohesiveness in healthcare. Strengthening of health governance at all levels and especially, at the local level through local government, community engagement, appropriate education and training of health workforce, task-shifting, use of IT-AI technology in screenings, diagnostics and therapeutics, digital health records and referral pathways and use of telemedicine, to name a few, are important areas to be strengthened/ introduced and aligned.

Sixth, wide ranging public-private partnerships are the only way to address the healthcare needs of the people.

Seven, in view of our history of natural disasters and growing manifestations of climate change, we have to be proactive in robust preparation for emergencies and their impact on human health in line with international health regulations. Emergency preparation, response and recovery should be important planks of our health strategy.

Health is a state of physical, mental and social well-being – not just an absence of disease. Only healthy children can go to school, healthy adolescents can learn skills, healthy mothers can take care of their children, households and jobs; only healthy adults can be productive and make economies grow. Improving healthcare is a healthy investment with high returns.

The writer is a former SAPM on health, professor of health systems and population health at Shifa Tameer-i-Millat University, and adviser on UHC. He can be reached at Zedefar@gmail.com