PHA-Exch> Pakistan: Social injustice is killing people by Kausar S Khan published in news paper DAWN 1st December 2008

[Claudio Schuftan]

From: iftikhar ahmed dociftee at hotmail.com


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     *Social injustice is killing people*


By Kausar S K

IT is now 30 years since the historic declaration of primary health care
(PHC) at Almaty was adopted. It was 1978 when under the dynamic leadership
of Hafden Mahler, director general WHO, health was defined by the global
leadership of health care as "a state of physical, mental and social well
being, and not merely an absence of disease and infirmity" (Article 1).

A foundation of hope was laid with the slogan 'health for all' (HFA) by the
year 2000. Health was also stated to be a right and community participation
was flagged as an imperative for improving health outcomes. Inter-sectoral
collaboration was recommended for creating conditions leading to better
health. By pointing out that health is not merely the absence of disease and
infirmity WHO had unequivocally stated the importance of preventive,
promotive and rehabilitative aspects of health care. Unfortunately, like
many developing countries Pakistan failed to achieve the PHC goals as
maternal mortality, infant deaths, malnutrition, continued their
embarrassing trends (while the number of medical colleges increased
steadily).

The PHC movement was derailed for various reasons perhaps the foremost being
the domination by the clinical model of health. In Pakistan, even today
nearly 85 per cent of the health budget is spent on tertiary care and
secondary hospitals located in the urban centres, which cater to the needs
of 15 per cent of the population. 85 per cent of Pakistan's population is
left to the mercy of services resting on 15 per cent of the health budget.
The doctor-nurse ratio continues to be opposite to WHO recommendation of
three nurses to a doctor (Pakistan has three doctors to a nurse), and a
minimal quality of life remains elusive as the government repeatedly fails
to monitor this crucial foundation of health.

PHC also suffered because it was reduced to some selective programmes —
immunisation, diarrhoea management (instead of ensuring clean drinking water
for all), some clinical services and health education. The transformative
vision of PHC was thus left to a handful of PHC diehards to be found in some
teaching/learning institutions in Pakistan. The debacle of the PHC does not
reflect any conceptual gaps within the PHC declaration. The failure lies
safely in the heart of the medical model of health which can't seem to grasp
two critical concepts: social determinants of health and health equity.

While countries like Pakistan continue to fail its vulnerable populations,
globally health concerns have moved forward. This progress is epitomised in
the 2008 report of the WHO Commission on Social Determinants of Health
(CSDH).. The very title is enough to send the thoughtful to their drawing
boards: 'Closing the gap in a generation — health equity through action on
the social determinants of health' (www.who.int/social_determinants). The
report makes three succinct recommendations: (i) improve daily living
conditions; (ii) tackle the inequitable distribution of power, money and
resources; and (iii) measure and understand the problem and assess the
impact of action.

Each recommendation carries under its heading more detailed recommendations
but the brief preamble encapsulates what needs to be done if health is to
imbibe the notion of justice for all. The first recommendation begins by
advising:

"Improve the well being of girls and women and the circumstances in which
their children are born, put major emphasis on early child development and
education for girls and boys, improve living and working conditions and
create social protection policy supportive of all, and create conditions for
a flourishing older life. Policies to achieve these goals will involve civil
society, governments, and global institutions." (Page 202.)

Care over the entire life cycle of a person, woman or man, poor or rich, has
been presented as an entitlement. Living and working conditions have been
highlighted for improvement, for in these two realms a person spends most of
her life. It is also important to note that policies are to be made in
consultation with civil society. Thus, the participatory/democratic
processes for making social policies are stated as given.

The heart of the second recommendation is to be found in the concept of
equity that the CSDH report emphasises in no uncertain terms:

"In order to address health inequities, and inequitable conditions of daily
living, it is necessary to address inequities — such as those between men
and women — in the way society is organised. This requires a strong public
sector that is committed, capable, and adequately financed." (Page 204.)

Equity in health helps unveil the inequities that in Pakistan are based on
injustices rooted in gender and class relations. It is well known that all
pregnant women do not die in child birth but it is the poor woman who does
not have access to emergency care and is more likely to die than a woman
from a middle- and upper-income bracket.. Similarly, if a husband and wife
both suffer from tuberculosis, it is more likely that the husband will
access available care. Inadequate food becomes the lot of girls and women
more than the male counterparts in the family.. Equity is a relative term
and reduction in inequities means monitoring comparison between different
social groups, e.g. class, gender, ethnic and religious minorities.

The third recommendation calls for making a system that could monitor the
impact of actions taken on the basis of the first two recommendations. The
three recommendations together offer a blue print for making a difference in
our society. Will the parliamentarians read the report so that they can
assess how the executive is performing in terms of the lives of the people
of Pakistan? Will health /medical institutions in Pakistan use the report to
examine their own thoughts and actions? Will the NGOs take advantage of the
report to accelerate their advocacy for creating better health conditions?
While these questions mark time, the closing statement of the report may
jolt some into action:

"Reducing health inequities is, for the Commission on Social Determinants of
Health, an ethical imperative. Social injustice is killing people on a grand
scale."




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