The link between poverty and health is well established worldwide, but the connection is both direct (lack of access to health services) and indirect (lack of awareness about health-related issues). Poverty helps produce ailments and ill-health pushes people towards poverty. It is a vicious cycle. Socioeconomic conditions create situations that can lead to ill-health. Health emergencies can cost individuals and families, dearly aggravating poverty. According to the World Bank, 25 percent of hospitalized people in India fall below the poverty line. In Pakistan, little research based on empirical data has been found to understand the link between health and poverty. However, a World Bank study found out that approximately four percent of the population in Pakistan falls into poverty due to health shocks each year.
Distribution of income is important for equitable access to healthcare. Income inequalities have been growing in Pakistan. The value of its Gini coefficient is hovering around 0.60. The inflation rate has been rising in the double digits for the last several years and food poverty has increased. According to the Household and Income Expenditure Survey (HIES 2011-12), 42.6 percent of household income is spent on food. On account of growing income poverty and rising food prices, the access to healthcare is curtailed. Corporate businesses have taken hefty loans from banks and their cost is passed on to ordinary clients. Individuals and companies have wrongly taken large amounts of power and gas; such costs were passed on to ordinary consumers as ‘line losses’ in their monthly utility bills. This nation lives in misery as the state continues to pursue policies that end in greater poverty.
The expenses of food and healthcare have increased for the poor. Increasing costs of healthcare have constrained access to health services. According to the Daily Dawn, the total national cost of medicine is expected to increase threefold from 2007 to 2014 — from one billion to three billion US dollars. Increasing poverty and poor health in Pakistan is understandable as the country’s GDP grew at an average rate of only three percent during the last 5-6 years in comparison to a nearly seven percent growth in the years preceding 2008.
In the last few years, newspapers in Pakistan have increasingly published stories about poverty-related crimes including theft, robbery, and suicide. Video clips show how poor workers snatch food offered to them after political meetings. Moreover, such scenes create a bad image among fellow citizens; a kind of self-inflicting strategy remains in place. Due to the high costs of modern healthcare, the incidence of seeking healthcare from quacks has increased. The bad stories about quacks have been aired on television, leaving an adverse effects on Pakistanis.
Poverty and Poor Health
Poverty and income inequality in Pakistan have been increasing during the last few years. Research shows that people with higher incomes tend to enjoy better health than those with lower incomes. The health status of families deteriorates when children get older and costs of living go up.
Poverty influences the health of children even before they are born. The growth of the fetus is affected by the nutritional status of mothers. This is understandable in the context of competing expenses between food and healthcare. Accordingly, the health of mothers has a strong bearing on the health of human populations.
Some problems about privatizing healthcare are even more disturbing. Human organs have been sold to people through many private hospitals. Out of extreme poverty, people have been forced to sell kidneys to the rich.
The Daily Dawn reports that food prices have increased by 217 percent since 2001. During the same period, prices of fuel have increased by 153 percent and the cost of power has gone up by 179 percent. In the same fashion, the cost of transport has increased by 166 percent. However, most of these prices increased in the last 5-6 years. These costs of living are important and adversely affect the access to privatized healthcare.
Some problems about privatizing healthcare are even more disturbing. Human organs have been sold to people through many private hospitals. Out of extreme poverty, people have been forced to sell kidneys to the rich. This business flourished, leading many individuals to travel from overseas to Pakistan for kidney transplants. This was a burgeoning business a few years ago, though apparently the incidence rate has come down.
Poverty and Mental Health
Poverty has a strong relationship with mental health. Stress, anxiety, and depression are frequently reported ailments that are linked to poverty. The number of people seeking psychological care has increased during the last several years. In a personal interview I had with a doctor in urban Lahore, he said that he gave a tranquilizer to 95 percent of his adult patients and hardly anyone complained about dizziness. This reportage was suggestive of the fact that many people suffered from mental problems; that is why sedatives were effective.
Various social and economic policies have been changing abruptly. These frequent policy changes have kept people engaged and anxious. The prices of energy change every month and new taxes are imposed as and when wished. Policies about imports/exports change repeatedly; office orders are issued and withdrawn frequently. The abruptness in policy and action has kept people tense.
In the context of increasing mental ailments, the number of divorces has multiplied in recent years. In February 2014, I asked a class of 47 MSC students at Punjab University if they knew someone among their friends and relatives that had experienced one or more divorces. Exactly 16 students (one-third) raised their hands. I asked the same question to find the incidence of separation between the couples; another 15 students raised their hands. I did this in another class of 45 students, and 12 of them reported that they had noticed at least one divorce among their friends and relatives, and one student reported one separation. In another class of 30 students, five students witnessed a divorce among their near ones during the last one year.
These spontaneous findings may indicate some exaggeration but growing poverty and inequalities do show weakening social relations, resulting into divorce and separations.
Privatization of Healthcare
The privatization of state machinery has been happening for the last several years. The health sector in Pakistan has become increasingly commercialized. Private hospitals, clinics, and diagnostic labs have been growing rapidly. Several chains of modern pharmacies have sprouted up in the market. Such a commercial approach to health has constrained the access to health services for the poor. The privatization of healthcare becomes an important issue because 75 percent of Pakistanis use private healthcare.
In a report on the privatization of healthcare in South Asia, Rama Baru, a research scholar, reported that privatizing health is detrimental to the health of poorer populations because it constrains their access to health services. Sometimes, food and other emerging social needs (for example attending marriage ceremonies of relatives) prohibit people from seeking healthcare. The Daily Dawn reported that drug makers in Pakistan have insisted that the government is the caretaker of a citizen’s access to healthcare, not the private sector. Private business operates for profit and the government should provide healthcare. Large pharmaceutical companies keep increasing prices of medicines, which is harmful to public health. Their profit motive originates from the fact that drug manufacturers have opposed the idea of marketing generic medicines; the policy of generic medicines provides inexpensive medicines to people in neighboring India.
The government wishes to expand access to healthcare in both urban and rural areas. New rules have been promulgated whereby the posting of doctors in rural areas have become mandatory. Various health insurance schemes have been debated-on for the sake of employees of large organizations and for the general public. This is done through the provision of direct transfers of money through medical allowances. However, the impact of direct money transfers seems to adversely affect the poor, as they have been using such meager amounts of healthcare money for other competing needs such as food and energy.
These arguments receive further support from Dara Carr, a technical director for health communication at the Population Reference Bureau, who stated that healthcare financing systems in developing countries have disadvantaged the poor.
Governmental provisioning of healthcare has been deteriorating during the last decade or so and has resulted in dissatisfaction, pushing people to opt for private care. For example, one low-ranking employee in my institute, despite having the option to seek healthcare from the public sector, preferred to hospitalize his wife in a private clinic. Table 1 shows general government expenditure on health as percentage of the gross domestic product (GDP) for selected countries and years. Only the countries that could provide a meaningful comparison are included. The data show that Pakistan spent three percent of its GDP on health in 2000, which fell to 2.2 percent by 2009. It may be noted that Pakistan has spent the smallest percentage of its GDP on health among all the countries shown in the table for all three given years.
Table 2 shows general government expenditure on health as a percentage of total government expenditure. The data show that only 3.3 percent of the total government expenditure was on health. It indicates the government’s priorities regarding health. With the exception of Afghanistan, every country in the table has spent higher proportion of government expenditure on health. The figure for Afghanistan is low because a large percentage (24.3 percent) of funds came from external resources (see Table 4). Although the percentage of funds spent on health increased from 1.3 percent in 2006 to 3.3 percent in 2009, the money, apparently, was spent on low-performing sectors, including tertiary care. As a result, the poor remain disadvantaged and such a skewed use of healthcare funds has contributed towards a rise in poverty. Accordingly, a higher proportion of money should be spent on preventive and primary care.
The role of government in healthcare is established, especially in developing countries. Table 3 shows general government expenditure on health as a percentage of total expenditure on health. Although government health expenditure has increased from 16.4 percent in 2006 to 34.8 percent in 2009, the health of the poor seems to have deteriorated. It is possible that the money may have been spent on providing new services or on infrastructure, such as the establishment of Burn Centers in different cities. Reportedly, 85 percent of the healthcare budget has been spent on tertiary health services, which are generally used by 15 percent of the population.
Table 4 shows external sources for health funding as a percentage of total expenditure on health for selected years and countries. The data show that external resources spent on health increased from 0.8 percent in 2000 to 3.2 percent in 2006 and to 4.4 percent in 2009. This increase over 9 years did not make much difference in the overall health status of the poor in Pakistan.
Production of Health as a Social Enterprise
Production of health or ill-health is a social enterprise. Psychosomatic diseases represent a major proportion of ill-health anywhere in the world. Social stress, anxiety, tension, and pressure create vulnerabilities for individuals. Although, both men and women suffer from the stressful social milieu, women have disproportionately suffered more from social stress than men. Unbridled individualism coupled with burgeoning materialism has produced high levels of anxiety in social relations.
Social support networks have weakened, and individuals have been left to deal with social pressures on their own. The institution of family has been weakening slowly. More importantly, the media is greatly influencing youth. They are internalizing the norms of popular culture and changing their attitudes towards women’s education, employment, and marriage. As of late, parents and families have become less relevant in such decisions.
Accordingly, stress levels and social conflict among young individuals have increased. Such a taxing social environment has produced psychosomatic diseases, putting more pressure on the healthcare system. Moreover, privatized and expensive health services make the problem even harder to address: Social production of ill-health can be understood in the context of issues related to day-to-day living. Increasing privatization of state functions has created inequities that have created tension and anxiety. In developed countries, the roles of state are transferred to private institutions in a planned manner but in developing countries, the situation conversely becomes worse. In Germany, for example, with the expansion of statutory social security and healthcare, friendly societies have declined. Some friendly societies have evolved into commercial insurance firms while others focus on providing recreational and cultural activities (Midgley 2011:20).
Social production of ill-health can be understood in the context of issues related to day-to-day living. Increasing privatization of state functions has created inequities that have created tension and anxiety. In developed countries, the roles of state are transferred to private institutions in a planned manner but in developing countries, the situation conversely becomes worse. In Germany, for example, with the expansion of statutory social security and healthcare, friendly societies have declined. Some friendly societies have evolved into commercial insurance firms while others focus on providing recreational and cultural activities (Midgley 2011:20).
It seems that the Pakistani state has been pursuing regressive policies. David Bloom and David Canning reported that poor health could facilitate social breakdown. A 1998 study commissioned by the CIA found that the best model for predicting a state’s failure is based on high levels of infant mortality, low openness to trade, and a low level of democracy. Societal conditions are strongly connected to the health of people; a harmonious and supportive society can bring health and happiness for people. In turn, “health is essential to building strong societies. The importance of a socially-based understanding of health is essential for improving health of populations” (Bloom & Canning 2001:6). Pakistani society remains under pressure due to on-going conflicts, especially the war on terror, within Pakistan and the region. Accordingly, the health of people has suffered greatly and poverty continues to contribute towards ill-health.
Health policy action during the last few years has actually been counter-productive for the poor. In January 2010, under an act of the Punjab Government, public sector organizations have changed their policy of providing free medicines to their employees.
At Punjab University, for example, the policy was replaced with a medical allowance equivalent to 15 percent of an employee’s base pay. The employees and faculty with higher salaries received relatively higher amounts of medical allowance, but the low cadre employees got meager amounts of healthcare money.
Additionally, the higher cadre employees were better educated and informed and therefore were not in as great of a need of healthcare compared with poorer colleagues or subordinates. The provision of healthcare through the facility was a kind of health insurance for all the employees, but the policy of medical allowance took that away from the poor. This policy action produced greater ill-health among the poor.
Through such a policy action, the access to healthcare for poor employees was constrained. In a conversation I had with the Chief Medical Officer of Punjab University, he said that the health of low cadre employees has deteriorated. Furthermore, on account of such a policy, people were shifting towards alternative healing methods, including the use of quacks. In turn, the rich-poor gap in morbidity and mortality has increased.
Pakistan’s health service needs detailed scrutiny and organized action. The per capita income in Pakistan in PPP dollars remains low (~US$2000). Most governmental health allocations (nearly 85 percent) have been spent on tertiary care (Islam 2002 in Afzal and Yousuf 2013). In Pakistan, preventive care and primary health services need maximum attention. Pakistan’s population is approaching 200 million, and this country must focus on preventive and primary care, rather than on expensive curative care.
Governments at national and provincial levels should allocate a greater proportion of funds for healthcare (possibly 5 percent of the GDP).
The emphasis of healthcare should shift from tertiary care to preventive and primary healthcare.
Privatized health should be encouraged to promote competition in the public sector, but the state should be vastly engaged too.
Generic medicines should be allowed (as in India) because the cost of branded medicines has been rapidly increasing.
Health-related awareness programs through media and schoolbooks should be launched to address social and cultural dynamics of health. The campaigns should focus on preventive strategies.
The public environment needs to improve for better hygienic conditions.
Clean drinking water should be provided to masses across the country including rural areas. Thailand has developed inexpensive filtration plants/devices; we can develop such filtration facilities in both urban and rural areas all across Pakistan.
Human relations need to be socially engineered in such a way that support structures could improve the health of individuals. Mental health must be given due attention as it remains a significant producer of ill-health. Pervasive conflict in public life should be addressed by promoting tolerance and the institution of family must retain its supportive role.