A security guard stands behind a barrier closing a street during a government-imposed lockdown as a preventive measure against the Covid-19 coronavirus, on the outskirts of Islamabad on March 24, 2020. Photo: AFP / Farooq Naeem

In early April, social media in Pakistan went abuzz with news and videos of police manhandling doctors in front of Chief Minister’s Secretariat in Balochistan province. The protesting members of the Young Doctors’ Association (YDA) were beaten and dragged away before being shoved into jail.

To demand much-needed personal protective equipment (PPE) for fighting Covid-19, the doctors had marched to the CM Secretariat to demonstrate, and the baton charge by the police was the result. The confrontation ended after the chief minister assured the doctors that they would be provided with all needed equipment to fight against the Covid-19 outbreak that has infected paramedical staff.

The event exposed the flaws in the province’s health-care system.

In Pakistan as a whole, the “reactive” measures across the country have been effective, particularly the lockdown, which has helped to curtail the contagion. However, a consistent increase in communicable diseases across the country indicates serious problems with the national health-care system.

On April 25, 2019, news about an outbreak of the human immunodeficiency virus (HIV) in Ratodero, a city in Larkana district, Sindh, caught the attention of national and international media. With the assistance of the World Health Organization (WHO), local and provincial health departments initiated screening for HIV cases in the area.

From April 25 to June 28, 2019, almost 30,132 people were screened, of whom 876 tested positive. The crisis put another dent in the reputation of the health-care system. It was a sudden prick in the bubble of claims that communicable diseases had been controlled in Pakistan.

In addition, for monitoring and early diagnosis of communicable viral diseases, the Pakistani government launched a Disease Early Warning System (DEWS) in 2005. However, the sudden rise in HIV cases in Sindh in 2019, the prevalence of hepatitis C virus (HCV) in the country and the onset of multi- and extensively drug-resistant tuberculosis (MDR/XDR TB) have raised concerns about the efficiency of DEWS.

The Covid-19 outbreak has affected the entire world. It will force health-care systems to adopt more proactive rather than reactive measures in future.

Pakistan has suffered devastating disasters throughout the course of history. Among the worst of these were the massive earthquake of 2005 and flash floods in 2010-11. Have these untoward events, in terms of reforms followed after the disasters, affected the health-care systems of Pakistan? Will the current Covid-19 outbreak push the federal and provincial governments to adopt proactive approaches to deal with disasters and pandemics in future?

In Pakistan, all efforts to deal with intermittent disasters have been reactive in nature. The mixed-reactive approach (including aid from civil society, private non-governmental organizations and the international community) could assist in reducing risk and severity during a crisis; however, a proactive approach, through legislative cover, would assist, if not prevent, the whole crisis, to diminish risk while giving space for preparedness.

Post-disaster health challenges

On October 5, 2005, northern parts of Pakistan and Azad Jammu and Kashmir (AJ&K) were jolted by an earthquake of magnitude 7.6. The disaster claimed 73,000 lives and left millions homeless. The response from the people of Pakistan was magnanimous. By October 13, the President’s Relief Fund had accumulated 7.1 billion rupees (more than US$44 million at the current exchange rate) in aid.

However, the infrastructural damage was too severe to manage. Government’s “reactive” response encountered numerous hurdles to carrying out relief aid in the mountainous parts of earthquake-hit areas.

Disasters such as earthquakes have multidimensional effects on the masses. Apart from physical damage to infrastructure and property, a severe health crisis follows.

A study conducted in the Kaghan Valley between 2006 and 2008 after the earthquake evaluated the disease patterns after the earthquake. It revealed that communicable diseases were prevalent in the valley for two years after the quake. The most common ailments were contagious viral upper respiratory infection and scabies.

This showed that the reactive measures to the disaster lacked a health capacity, and could not resolve health conditions on a war-footing basis.

The earthquake could not be marked as an agent of change. However, it could have proved an accelerant, if not a catalyst, in terms of forging a way for policy enactment.

In 2010, massive floods claimed 1,800 lives. Some 20 million people in 78 districts were affected and 2 million homes were destroyed or damaged. The floods were not an exception in terms of carrying a huge cache of viral and infectious diseases as an aftermath of the disaster.

The World Health Organization (WHO) warned that a rise in waterborne diseases, including viral and infectious diseases, could intensify as the country was still grappling with the issue of rehabilitation of people displaced during the 2005 earthquake.

On a similar note, the WHO also cautioned about health indicators not doing well in the post-earthquake areas. Moreover, on August 17, 2010, the United Nations Children’s Fund (UNICEF) estimated that 3.5 million children were at risk of being affected by waterborne, viral and infectious diseases.

Neither of these major events induced reforms in the health-care system, but they did help pave the way to the National Disaster Management Authority (NDMA) in 2007 and Earthquake Reconstruction and Rehabilitation Authority (ERRA) in 2005. Yet there remained a vacuum in terms of interlinking disaster risk reduction with health issues.

The 18th Amendment

The year 2011 saw a watershed moment in Pakistan. It was a year of optimism about decentralization of power through 18th Amendment of the constitution. Hopes were sustained that this would eventually improve the health-care systems among other subjects that fell under provincial cover.

Indubitably, the 18th Amendment was a landmark achievement in the history of Pakistan. It was rightly termed the right path to lead the nation toward becoming a true democratic state. However, decentralization has proved to be an impediment to improving the health-care system.

The first drawback was observed soon after three provinces passed bills related to health, while Balochistan failed to do so. Thus the provinces, except Balochistan, committed to ban quackery and ensure equal health opportunities for the masses. Nevertheless, equal access to quality health services and drug-resistant microbial ailments are two grave issues to resolve despite decentralization of health administration after the 18th Amendment.

The health delivery systems at primary and secondary levels have become more complicated after the devolution given the bad governance and lack of transparency at the provincial and federal levels. The overall health-care system is overseen by five health ministries that often squabble while forging a coalesced decision on health-related issues.

The recent tussle between the federal and Sindh governments over the Covid-19 lockdown is a glaring example. Similarly, the Balochistan government was left alone with paltry resources to deal with the inflow of pilgrims from Iran, quarantining them and managing isolation, which led to mishandling of the situation.

Health Vision 2016-25

Pakistan has gained improvement in some health indicators. Life expectancy, which was 59 years in 1990, has increased to 67. Similarly, the maternal mortality rate has decreased. In 2006-07, it was 276 per 100,000 live births.

However, Pakistan still suffers from a high disease burden. In order to cope with it, the government announced Health Vision 2016-25. The vision retains a broader approach to diminish health risks while improving governance and financial issues. Moreover, the vision aims to smooth the coordination among primary, secondary and tertiary health services.

Currently, Pakistan seems to be stuck in the whirlpool of the Covid-19 crisis, as almost all nations of the world have been facing it. Covid-19 is the worst health crisis in the recent history of the world. Pakistan has been effective in dealing with Covid-19 crisis so far. The lockdown has served its purposes and has slowed the surge in positive cases.

However, the overall health-care system has fallen under a spotlight. Will the Covid-19 outbreak serve as a catalyst to revamp the entire health-care structure on the basis of proactive approaches in order to encounter, if not to ward off, a massive health crisis in future?

Ayaz Khan

Ayaz Khan is a freelance journalist and researcher from Pakistan and a member of Climate Tracker Asia. He is also a digital media fellow at Massachusetts University Amherst. He tweets at @Ayaz_Jurno.