Conserving Human Capital

Written by Sara Iqbal • November 2011

The Pakistani population has a lot of potential. Efforts for providing a conducive environment to help promote sound mental and physical health are imperative for a healthy and productive nation. Health plays a key role in determining the quality of human capital. Better health improves the efficiency and productivity of the labor force and ultimately contributes to economic growth and human welfare. However, successive governments in Pakistan seem to have missed out on this core issue of national progress.

The latest Economic Survey of Pakistan (2010-2011) paints a bleak picture of the health sector. Spending on health remained abysmally low and declined as a percentage of GDP. Total public sector expenditure on health, for both the federal as well as provincial governments combined, in this past fiscal year was 0.54 percent of the GDP.

The year also saw a decline in health expenditures to Rs. 42 billion from Rs. 79 billion the previous year, a reduction of 0.23 per cent of GDP. This is contrary to the progressive increase in the health budget over the past several years, with Rs. 24.3 billion being spent in 2000-01 and Rs. 79 billion in 2009-10.

The numbers come as a surprise if one considers a number of vertical and horizontal programs regarding health facilities that are operative in Pakistan. These include:

Lady Health Worker Program; Malaria Control Program; Tuberculosis and HIV/AIDS Control Program; National Maternal and Child Health Program; the Expanded Program on Immunization; Cancer Treatment Program; Food and Nutrition Program, and; the Prime Minister Program for Preventive and Control of Hepatitis A & B. Similarly, to effectively address the health problems facing Pakistan, a number of policies emphasize better health care services. These include: Health related Millennium Development Goals; Medium Term Development Framework; Poverty Reduction Strategy Papers; National Health Policy and Vision 2030.

However, in all these statistics, what our policymakers tend to overlook is the bulging population of Pakistan. Standing as the world’s sixth-largest country at an estimated 175 million people with the highest population growth, birth, and fertility rates in South Asia, these sheer numbers are a greater threat for Pakistan than all the problems combined, including militancy, a fragile economy and natural disasters.

Besides an acute shortage of expertise to address the problem, there are many social stigmas associated with mental issues that hinder identifying and treating the problem. Many people, most particularly in rural areas, still believe mental ill-health is caused by ‘evil spirits’ entering the body of a person. This kind of superstition makes it crucial that awareness and sensitivity be created. Thus they are less likely to report their mental state to a physician, and may go to the aid of pirs and faqirs instead. This may only reaffirm their superstition, which in turn contributes to the vicious cycle of mental health miseducation.

The issue becomes graver here when it is regarded as gender-driven. Pakistan Association of Mental Health reports that women suffer from clinical depression more than their male counterparts partly due to their marginalized status in society.

The reason is quite understandable, given the societal attitudes and norms, as well as cultural practices (Karo Kari, exchange marriages, early marriages, dowry, etc.) that play a vital role in women’s mental health. The religious and ethnic conflicts, along with the dehumanizing attitudes towards women, the extended family system, role of in-laws in daily lives of women, pressure to produce a male heir, lack of proper health facilities for pregnant women, lack of social support for nuclear family mothers in urban areas represent major issues and stressors. Moreover, violence against women has become one of the acceptable means whereby men exercise their culturally constructed right to control women. Such practices in Pakistan have created extreme marginalization of women in numerous spheres of life, which has had an adverse psychological impact.

Moreover, the Mental Health Ordinance, introduced in 2001 to replace the Lunacy Act of 1912, remains poorly implemented. The ordinance attempted to introduce more enlightened psychiatric care, particularly in state-run institutions and laid down rules to prevent the mistreatment of patients. But little has come of it. Even at leading institutes for mental health, there are continued reports of patient mistreatment or a failure to provide adequate care.

When we come to health services, though the major teaching hospitals across the country have established separate departments of psychiatry but in most cases they are not well equipped specially in terms of psychiatric manpower both skill and number wise. Also, Pakistan’s already low numbers of psychiatrists are continuously being drained by the developed countries where they are being offered an attractive package and lifestyle thereby minimizing their chances of returning and serving the nation.

On the other hand, the hospitals with limited mental treatment facilities also don’t follow the prescribed admission criteria; there are no separate units for subspecialties, no appropriate long stay units, no exit/discharge criteria, no rehabilitation services and no exchange of information between psychiatrists and family practitioners. There is a dearth of proper advertisement of available services, no concept of day centers or day hospitals, ill developed community services, no central registry of patients and set policy for management systems in the psychiatric set ups and finally no internal referral system.