RESEARCH ON HEALTH FACILITIES AND NEEDS IN RURAL AREAS

Health Facilities in Rural Areas of Pakistan

     By far the rural areas of Pakistan have remained deprived of major health reforms throughout our 60 year history like as if they never fell in our geographic boundaries and it is overwhelmingly sad to know, these off radar rural areas should be made part of stream of facilities availed by urban area as we have 67 % of our population living in rural areas and more importantly they are equally as much human beings as we living in the cities are. In Pakistan the health sector has been badly neglected and the policy makers have shown a callous lack of concern for educating the people and providing them with health care. No wonder, the quality of life of the people has remained low and the nation has not been able to achieve higher levels of economic progress due to underdeveloped human resources. The under-development of the health sector is manifested in Pakistan’s poor health-related key indicators. Life expectancy at birth is 59 years while the average for other comparable countries is 61 years. The infant mortality rate is 95 per thousand as compared to 60 in other countries. Expenditure on health as a percentage of GNP also remains low. The operational strategy should be to encourage greater involvement of the private sector. Though the government is trying to improve the health and nutrition status of the country through promotional, preventive and rural services. Extended programs of immunization, nutritional and child survival, accelerated health, matching grants for health projects and greater role for the private sector are some of the areas witnessing progress during the year. A new cadre of community health workers needs to be created to act as a bridge between the community and health units through the Social Action Programed (SAP). In rural health the emphasis will be on the up gradation of Basic Health Units (BHUs) and Rural Health Centre’s (RHCs).

      Adequate food availability, water supply and sanitation will also be included in this programme. Health facilities in Pakistan are inadequate, mainly due to a lack of resources and a high population growth rate. The country needs food, a proper water supply, and adequate sanitation. However, Pakistan is the first country to nearly completely eradicate dracunculiasis (disease), having reported fewer than 100 cases in 1995. Pakistan is also working toward universal immunization, disease prevention, health promotion, and curative and rehabilitative services. Several programs are under way to improve health care coverage and control tuberculosis, leprosy (disease), and cancer. One such program was a Child Survival/Primary Health Care program to reduce mortality, malnutrition, and deaths due to diarrheal diseases. As of 1999, 36% of children under five years old were considered malnourished. The goiter rate was high in 1996; 40 of every 100 school children were affected by goiter (disease). In 1997, 90% of children up to one year of age were immunized against tuberculosis; 74% against diphtheria, pertussis, and tetanus; 74% against polio; and 74% against measles. There were an estimated 0.6 physicians and 0.7 hospital beds per 1,000 people. In 1993, there were 302 health centers with 2,462 beds serving the rural population. In 1991, centers for the disabled included 11 physical therapy centers, 12 mental retardation centers, 11 centers for the visually impaired, and 12 centers for the hearing impaired. In 2000, the infant mortality rate was 83 per 1,000 live births. Major causes of infant mortality are immunization diseases, diarrhea, malnutrition, and poor environmental sanitation. In 2000, 88% of the population had access to safe drinking water and 61% adequate sanitation. The estimated overall mortality rate was 9 per 1,000 people in 2002. The leading causes of death were diarrhea, pneumonia, tuberculosis, cardiovascular diseases, and cancer. Average life expectancy in 2000 was estimated at 63 years. Condition of rural areas is still grave as doctors prefer to work in urban areas with more salaries and comfortable lifestyle. There is no opposing the fact that the prosperity and development of a state mainly depend upon the health of its citizens. If the citizens are physically powerful and well built, then the state can go ahead in all fields of life. In this way the children having sound health and active bodies lay the foundations of the edifice of a strong state (nation). The sound health and body of the children also depend upon the good health and sound body of their mothers. If a mother is good, energetic and healthy, at last her offspring will also be healthy. The first five years of the child after the birth are very important for his/her life to come. A weak and ill mother will not only affect negatively the health of her children but also become a trouble on the whole members of her family. Especially the time period between pregnancy and delivery is very important for both the mother and the child. Without proper precautionary measures and viable medical treatment, there poses a constant threat to the life and existence of the both.

      Experts say that at the time of delivery, precautionary measures must be taken to thwart the possibilities of any bad results. It is also pertinent to note here that the high ratio of death and deceases among the children and women during the time of pregnancy and delivery is one of the major health problems in Pakistan. According to a reliable estimate about 13 000 mothers annually die during the time of delivery. Most of them belong to rural and backward areas, where there is no transaction and provisions of health facilities to the poor and down trodden segments of these areas. It is also known that the mortality ratio in rural areas is twofold as compared to the urban areas. Likewise, according to a good estimate 4, 00,000 children die every year before reaching their first birth anniversary, While 2,30,000 among them hardly reach first month of their birth. According to experts of medical science, the lack of knowledge and awareness among the mothers, family members of our society is one of the main causes of all this unfortunate incidents being faced by the innocent people in rural areas.

    Actually the oldest and outdated customary methods being used at the time of delivery and pregnancy are harmful and fatal for the health of mother and her child. During the pregnancy, the mother is not being given balanced and prescribed diet. The four major causes of the mother mortality during pregnancy and delivery is the flow of too much blood, infection, high blood pressure and hurdles, impediments and complications in the way of delivery. To avoid all these perils and hazards, precautionary measures must be taken by women for their own as well as for their babies’ well-being. During pregnancy the mother should be examined at least four times by a qualified lady doctor or the relevant lady health workers deployed in the nearby hospitals. In nutshell a full pledged drive and campaign should be launched to create awareness among the mothers regarding the hardship and impediments coming in their way. The health department shall focus more on the issue to yield maximum positive result in order to save the future of millions of women and children of the rural region. I would suggest to the public representatives, community leaders, media persons, religious scholars, government officials and the teachers community to play their vital role to spread this noble message to each and every member of society. Only in this way we can protect and preserve the future generation of our country. More than half of the rural population is deprived of quality health facilities, according to the Free and Fair Election Network (FAFEN) monthly report. However, compared to all other provinces, health services/facilities in the Rural Health Centers (RHCs) of Punjab are better.

      The report blames weak oversight by elected representatives, and unequal distribution of basic equipment, services, and medical staff at RHCs for their poor state. The monitoring was done in September 2010 by FAFEN (a coalition of 30 leading Pakistani civil society organizations in 83 RHCs nationwide. This includes 36 in 25 districts of Punjab, 22 in 18 districts of KP, eight districts of Baluchistan and 17 in 14 districts of Sindh. FAFEN was established in 2006 to observe the election process, educate voters, and advocate for electoral and democratic reform. It was found that 98 per cent of all monitored RHCs were appropriately set up, while the buildings of one-fourth of the monitored facilities were in decrepit condition. The report revealed that one fifth of the monitored RHCs across provinces lacked cleanliness and basic hygiene. This was despite the fact that 94 per cent had serving sanitary workers. Only three of 16 RHCs where cleanliness was an issue did not have serving sanitary workers. Better management and oversight and an increase in the number of sanitary workers may improve the better hygienic conditions, the report suggested. Almost one third of the monitored RHCs either did not have latrines or had latrines without running water. All provinces were somewhat short on staff except Sindh, where male and female doctors were in excess by 16 per cent and 25 per cent respectively. Likewise, 53 per cent paramedic personnel and 50 per cent nurses were in addition to the sanctioned posts in Sindh. The excessive staffing may be a result of deputations within healthcare system. Baluchistan was found to be most deficient in female staff, maternity and family planning facilities. During a day-long monitoring, female staff was not found on duty in half of the observed RHCs and family planning counseling staff was absent in three-fourths of the RHCs. The province has no sanctioned posts for nurses at the RHC while one-fourth of the sanctioned positions for doctors were vacant. In addition, more than three-fifths of the facilities had no labour room and nearly two-fifth did not have the delivery kit to facilitate childbirth. While all RHCs monitored in Punjab were equipped with oxygen tent, three-fourths of RHCs in Baluchistan, half of RHCs in KP and two-fifths of RHCs in Sindh did not have this essential and low-cost life-saving device.Availability of free medicines from the in-house pharmacies was confirmed from over 90 per cent of the observed RHCs nationwide.

      This grim picture of the deteriorating health situation could be seen in the annual health report of the Pakistan Medical Association (PMA) for the year 2011, which says one child dies every minute from EPI (expanded program on immunization diseases), diarrhea and acute respiratory infection (ARI). The report also reveals that every year about 400,000 infants die in the first year of their life. Child health in Pakistan is among the most important national issues that need serious attention. Child mortality in Pakistan is a major cause of concern, with every one among 10 children dying before reaching the age of five and one among 30, just after they are born. Pakistan is among the developing nations of the world that has yet to do much for the welfare of the general public. Pneumonia and air pollution seem to be the factors affecting the health of Pakistani children. The air pollution is mostly caused by harmful emissions of biogas, which is used in most houses of Pakistan. The main reason behind growing child mortality in Pakistan is lack of child healthcare facilities in rural areas, where majority of population lives. Low state spending on healthcare, abject poverty, low literacy, lack of skilled birth attendants, widespread communicable diseases, insufficient emergency child health services in government run district and rural hospitals are amongst other major reasons behind growing diseases in children. Maternal, newborn and child health care statistics in Pakistan are some of the poorest in South Asia. A holistic approach is needed to improve maternal and newborn health, mainly by improving and upgrading facilities at the district hospitals. Most common and lethal diseases in Pakistan include (ARI) acute respiratory, infection, viral hepatitis, malaria, diarrhea, dysentery, scabies, goiter, hepatitis and tuberculosis. Among the victims of acute respiratory infection (ARI) most vulnerable are children whose immune systems have been weakened by malnutrition. Majority of children visiting hospitals and dispensaries suffer from the respiratory ailments and serious attention is needed to provide better medical treatment to children living in rural areas. Viral hepatitis, particularly that caused by types B and C are major epidemics in Pakistan with nearly 12 million individuals infected with either of the virus. The main cause remains massive overuse of therapeutic injections and reuse of syringes during these injections in the private sector healthcare. Children are also amongst the hepatitis patients and their number is growing sharply. Malaria is a problem faced by the lower class people in Pakistan.

      The unsanitary conditions and stagnant water bodies in the rural areas and city slums provide excellent breeding grounds for mosquitoes. Like adults, children also suffer from malarial diseases, which need serious attention of healthcare policymakers. Diarrhea is rampant in the country due to use of contaminated water. It is estimated that about 20 per cent of diarrhea patients are children. Similarly, diseases like dysentery, scabies, dengue, and goiter are also on the rise. Expanded Programme on Immunization (EPI) Pakistan provides vaccination against childhood tuberculosis, poliomyelitis, diphtheria, pertussis, tetanus, hepatitis B, hemophilic influenza type b and measles, besides protecting pregnant ladies with tetanus toxoid and their neonates against neo-natal tetanus. However, there is no success even to control polio. Most births which take place at home under untrained supervision, which are responsible for alarming mortality of mothers and newborns. Children under the age of five face multiple obstacles, including birth injuries and infectious diseases. Millions of children suffer from short- and long-term adverse consequences of illnesses, malnutrition and injuries that impact their well-being and options in life, major numbers of them in rural areas. Child health is closely related to maternal health, as nutrition during pregnancy, birth conditions, birth spacing, and health status of the mother impact the health of the child prior to, during and after birth.

    Rural areas substandard health facilities are not up to mark to cope up with these grave issues of concern. Largely because of these factors, three million infants are stillborn each year. The recent devastating floods in Pakistan have further increased the disease burden. United Nations Children’s Fund (UNICEF) says as many as three and a half million children in flood-ravaged Pakistan may be at risk of contracting deadly diseases carried through contaminated water and insects. UNICEF says the greatest threats to public health in Pakistan at the current time are certainly from waterborne diseases, which can intensify in precarious hygiene conditions, and when people have limited or poor access to safe water and sanitation services. Diseases like cholera or acute watery diarrhea, dysentery & typhoid fever and hepatitis, can all cause excess mortality and morbidity amongst the susceptible populations in the flood-hit areas. There is also an increased risk of malaria and dengue fever, since the stagnant water may provide an ideal breeding ground for mosquitoes – the vector that is responsible for transmission. To cope with the situation, the government must open more children hospitals in the country. In Sindh province, there is just one big children hospital, National Institute of Child Health (NICH), running in Karachi by the federal government. There is dire need to open more children hospitals in the province and improve children departments in the hospitals of government-run teaching colleges in Karachi, Hyderabad, Jamshoro, Nawabshah, Sukkur and Larkana and all the rural areas people don’t have access to urban areas or city likes Karachi so the accessibility needs to be catered and health facilitation net to be extended to rural areas and make rural areas be part of rest of country and not to be treated like a deprived part as they are all Pakistani too and deserve the same care we the urban are having . In order to save lives of children, pediatric wards should be opened in all district headquarter hospitals, where emergency services along with trained staff be made accessible.