The writer holds a PhD from the University of Birmingham, UK and works in Islamabad.The People’s Primary Healthcare Initiative-Balochistan is another success story that we must highlight so...
The writer holds a PhD from the University of Birmingham, UK and works in Islamabad.
The People’s Primary Healthcare Initiative-Balochistan (PPHI-B) is another success story that we must highlight so that some positive developments in Balochistan can come to notice, both nationally and internationally. Of course, we cannot attribute the success of this project to an individual. It is the work of multiple teams, the board of directors led by eminent writer Munir Badini, and the donors that have contributed immensely.
Several stakeholders have guided the PPHI-B by their knowledge and expertise so that it can implement its mission tasks and initiatives. Primarily, it has worked to improve the quality of health services across Balochistan. Though overall the health department of the government of Balochistan is responsible for providing an enabling environment to the PPHI-B, its young CEO Aziz Jamali has worked wonders. Supported by partners such as the WHO, Global Fund, JICA, Mercy Corps, the National Health Institute (NHI) Islamabad, and some others, the PPHI-B is transforming the health scene in Balochistan. The Institute of Public Health in Quetta and the Health Services Academy Islamabad have also helped it.
The same applies to organizations such as BRSP, NRSP, IDSP and Jhpiego which have supported this initiative. This model is based on contracting out the management and execution of primary health services to PPHI. The 18th Amendment introduced by the PPP government in 2010 further enhanced provincial autonomy and empowered the provinces in this regard. As a result, so far nearly 700 Basic health Units (BHUs) and Health Facilities (HFs) across the 33 districts of Balochistan have come under the administration of the PPHI-B. Perhaps the best part is that the PPHI-B operates as a not-for-profit registered company with a board of directors.
Here it is important to understand that primary healthcare refers to the first point of contact between a patient and the health system usually via one or more health professionals at a BHU. Sometimes, primary healthcare also refers to emergency room visits. It may include curative care, disease prevention and health promotion in a particular community. Ideally, it should be free and the state should be held accountable if it fails to provide primary healthcare in every nook and corner of the country. Although without addressing the issues of poverty most problems remain unsolved, the PPHI-B is contributing its bit to address at least some issues in the health sector.
It is governed by a sound legal and regulatory framework which helps in its autonomous functions. The PPHI-B appears to be committed to health equity without which no social justice can be complete. Another feature that one can observe is its stress on community participation not only in defining but also implementing its health agenda. It has also acquired appropriate technology to respond effectively to health management challenges. The PPHI-B has not only focused on improving public health in rural areas but also in urban slums and has been able to reduce preventable mortalities, especially among women and children.
A major problem that the public health sector faces across Pakistan is low capacity of healthcare providers, and Balochistan is even worse in comparison with other provinces. To counter this, the PPHI-B has evaluated the healthcare services in Balochistan. Without such evaluation, no improvement could be achieved in the first place. Second, it managed and monitored the health infrastructure across the province. As a result, a focus on BHUs and HFs started helping the local populations, at least in some of the areas of primary health. An imbalance between primary and secondary care still exists and a lot needs to be done to reduce such disparities in Balochistan.
Primary care cost and equity still remain a challenge as even with donor support they cannot be met adequately. Being a garrison state focused on security, Pakistan has overall neglected the human development and welfare needs of its people. After the 18th Amendment, the provinces have tried to alter their preferences to some extent and that has helped the PPHI-B too. Defining priorities has been one of the features of the PPHI because once it was able to prioritize it could measure primary care and improve practices leading to noticeable reforms in healthcare.
Another achievement of the PPHI-B is its transition in focus from therapeutic to preventive medicine which is essential to reduce hospitalization rates. That includes cultural and environmental factors that contribute to diseases. Though the PPHI model is working in other provinces too, the scattered nature of population and rough territories in Balochistan make it even more challenging and it becomes a literally uphill task to offer health services across the province. Now with improved health facilities, the ageing population has also become a challenge. While previously maternal and neonatal mortality were the primary concerns, now communicable and infectious diseases have doubled the burden, especially in the wake of the covid-19 pandemic.
Luckily, the Balochistan Nutrition Programme was already underway when the Covid-19 pandemic descended on Balochistan. The project completed in December 2019 just a couple of months before the advent of Covid-19. The timely completion of this project left Balochistan slightly better prepared thanks to the PPHI-B. But malnutrition is still there and must be tackled by the donors and the government of Balochistan by providing more funds to the initiative.
Another challenge that the PPHI-B is facing relates to stunting and wasting among children below five years of age. This comes from anemia among women of productive age. And that in turn emanates from food insecurity and lack of livelihood resulting in rampant poverty.
It is alarming that Pakistan ranks fifth in the world in terms of the largest number of unimmunized children, and Balochistan taken separately is even worse. This is while we claim to be the seventh atomic power in the world and Balochistan was the locale for the atomic detonation. The PPHI-B is lucky to have Aziz Jamali as its CEO and Dr Ameer Bakhsh as its technical director, and of course their teams support them to achieve the targets. By the end of 2020, another 100 or so BHUs are expected to be functional.
The PPHI-B model appears to be both: efficient and flexible. It has been efficient as most BHUs under its purview are functional and operating, of course with limited medical and professional resources. Now there is a need for a massive scaling-up of immunization of children under one year, and reduction of malnutrition among children under five years. In the same token, population growth is an issue that we need to tackle. The population growth rate in Pakistan is nearly 2.5 percent, whereas in Balochistan it is nearly 3.4 percent.
With a population of 13 million people scattered across the vast arid and hilly areas of Balochistan, the teams of the PPHI-B are putting their heart and soul into their meagre resources, and must be appreciated. Now the PPHI-B must conduct more independent evaluations and consistent monitoring mechanisms must be in place to continue working. Regular assessments of its work are in order, which must go beyond its own routine monitoring. To remain effective, it needs independent reviews. In the end, to prove my point, let me give some solid numbers.
In Awaran for nearly 50, 000 children, the PPHI-B runs only seven BHUs, whereas for 90, 000 children in Barkhan, it also has just seven BHUs. For a hundred thousand children in Chagai it has only 11 BHUs; and let’s not forget: this was the district we used for our nuclear experiments.