Health is the most important factor in human life. In Pakistan, attempts have been made to improve the health conditions of the people through availability of trained personals, adequate supply of medicines and establishment of health services. Yet, the health care system as a whole is not what it ought to be and is still deficient in many respects. The main health problems are preventable communicable diseases; sever malnutrition and high incidence of birth resulting in a high proportion of infant and maternal mortality. There are also clear differentials in health conditions by rural and urban areas and socio economic groups. Malaria, tuberculoses and a wide variety of childhood diseases, such as, diarrheas, measles and tetanus etc. still continue to pose potential threat to the health of million of people in the country. Unsanitary conditions, polluted water, illiteracy among rural mother, urban slum and high fertility, small budgetary allocations and inadequate administrative structure have been identified as the main hurdles in the progress of health conditions.

The Government has taken many steps to improve the health of the people. Many specific programmes that deal with the major public health problems of the country are under execution. The Expanded Programme of Immunization (EPI) against six diseases to reduce infant and child mortality is under implementation. Health education has become an important component of all health initiatives. Private Sector has been involved in supplementing Government's efforts and financial allocation has steadily been increased.

Health Indicators
In Pakistan, the growth of health infrastructure is fairly slow and inadequacy of such health services is reflected in the very high rates of infant mortality, child death and low life expectancy in comparison to other countries of almost similar levels of development. Infant mortality rate in Pakistan is 91 per 1000 (1998) and the life expectancy at birth is 62 years. These figures reflect poorly the health status of the country in comparison with other countries of the region (Table-12.1):

Health Facilities
The health concept not only includes freedom from communicable and other diseases but also availability of facilities for maternity and child care. The infrastructure of health sector, therefore covers establishment of hospital, dispensaries, basic health units and maternity child health care centres and their staffing with adequate number of doctors, dispensers, nurses, lady health visitors and midwives. The existing national network of health services in the public sector consist of 877 hospital, 4625 dispensaries, 530 Rural Health Centres (RHCs) and 5152 Basic Health Units (BHUs) The total availability of beds in these health facilities is
estimated 91,919.

The number of registered doctors has increased to 87,105, dentists 3,867, nurses 35,979, lady health visitors, 5,299 and midwives 22,401. The population in relation to medical persons works out at 1,578 persons per doctor, 35,557 per dentist and 3,822 per nurse.

Source: World Development Indicators 2000.

Source: Ministry of Health and Planning & Development Division.

Private Sector
Both the public and private sector are providing medical facilities in the country but the private sector has concentrated in the urban areas. The private sector include two different types of facilities. These are allopathic and eastern systems of medicines. A large portion of these are in the urban areas. However, in the rural areas the indigenous midwives still handle majority of births. The Government has provided many fiscal and monetary incentives to the private sector to expand its role in the health sector. Tibb, Ayurvedic and Homeopathic system have been recognized by the Government in view of their coverage. In recent years, thousands of new medical centres have been established over the country. Majority of these private centres/clinics are run by reputable medical professionals. The increasing involvement of the private sector in health facilities is a positive development, as it not only provides health facilities but also a big source of employment for thousands of doctors and other technical and non-technical staff.

Physical Targets and Achievements during 1999-2000.
The physical targets of the public sector development programme, 1999-2000 include establishment of 18 Basic Health Units (BHUs), and 34 Rural Health Centres (RHCs), upgradation of 33 RHCs, and 53 BHUs; construction of 6 Urban Health Centres (UHCs), and addition of 2,300 hospital beds. The manpower development targets include the output of 4,400 doctors, 440 dentists, 3,000 nurses, 6,800 paramedics and 9,600 traditional birth attendants (TBAs). Under the immunization programme, 5.0 million children were to be immunized and 30 million ORS packets were to be distributed.

The health programme during the year has realized 65-100 percent of the physical targets for its various components. These achievements include: construction of 40 new facilities (12 BHUs, 22 RHCs, 6 UHCs), upgradation of 57 existing facilities (35 BHUs and 22 RHCs) and addition of 1,840 hospital beds. In health manpower development, 3,388 doctors, 308 dentists, 2,460 nurses, 5,304 paramedics and 7,872 birth attendants have been trained. On the preventive side, 4.0 million children have been immunized from six killer diseases (polio, measles, whooping cough, tetanus, diphtheria and tuberculosis) and 23 million ORS packets distributed to children, below 5 years of age against diarrhoeal diseases. The overall success rate has been 77.6 percent. Physical targets and achievements during 1999-2000 are given in Table-12.3:

Source: Planning and Development Division.

Public Sector Outlay
Total outlay on health sector (federal plus provincial) during 1999-2000 is Rs 14.6 billion (Rs 9.1 billion current expenditure and Rs 5.5 billion development expenditure), including 2.7 billion as federal allocation. The expenditure on health is 0.5 percent of GNP as shown in Table-12.4.

Source: Planning and Development Division.

I. HEALTH PROGRAMMES

There are several major health programmes which include: primary health care programme, expanded programme of immunization, health education programme, malaria control programme, tuberculosis control programme, cancer control programme, and AIDs prevention and control programme. The on-going development programmes are discussed in the following paragraphs.

i) National Programme for Family Planning and Primary Health Care
The programme is aimed at achieving universal health coverage and providing door to door primary health care facilities for a large segment of the population. Currently, the programme is being implemented in almost all the districts of the country with field work force of 44000 Lady Health Worker(LHWs), delivering services in the field of family planning, maternal and child health, immunization, nutrition and treatment of minor ailments. There are over 8841 trained officials and 1300 supervisors in the field of operation to provide training to LHWs and supervise their work. The programme has made significant achievement and for 1999-2000, an amount of Rs 1300 million has been allocated for the training of LHWs and purchase of materials, medicines and equipment.

ii) Expanded programme of Immunization.
An expanded programme of immunization (EPI) against six diseases i.e. tuberculoses, diphtheria, tetanus, persusis (whooping cough), measles and poliomyelitis are under execution alongwith a programme of production/distribution of oral rehydration salt (ORS) packets. The overall objectives of the programme is to reduce mortality among infants, children and Women, resulting from the six EPI target diseases. EPI has significantly progressed in terms of immunization coverage and diseases reduction. During the current year 1999-about 2000, about 4 million children have been immunized and 23 million ORS packets have been distributed. A sum of Rs 800 million has been earmarked for EPI programme for purchase of vaccines, syringes, cold chains and training needs.

iii) Malaria Control Programme(MCP)
Malaria is still a public health problem in Pakistan, as it continues to pose a risk to the health of the people in the country. A project with an objective to reduce the occurrence of malaria is already under implementation. An amount of Rs 90.0 million has been allocated for malaria control programmme for 1999-2000. Main activities undertaken during the current year under review include: undertaking of selective spray in highly malarious areas, collection of 1,497,895 blood slides and treatment of all confirmed malaria cases, with suitable antimalria drugs.

iv) AIDS Control Programme
The National Aids Control Programme with its four main components (information education, Prevention and Care of Transmitted Diseases, Surveillance and Safe Blood Transfusion), aims at preventing HIV transmission and reducing morbidity associated with HIV/AIDS. A sum of Rs 80 million has been allocated for 1999-2000 for carrying out the activities of the programme. Nearly, 0.150 million blood bags have been screened for HIV and Hepatite B and about 8000 - 9000 HIV anti body tests, performed during the course of year.

v) Cancer Programme
Cancer cases in Pakistan have increased since the last one decade because of access to more and better health facilities and diagnostic equipment. Environmental conditions, smoking, poor living conditions and dietary habits are known causes of the disease. At present, there are 23 centres in the country providing treatment to the cancer patients. Twelve of these are operated by Pakistan Atomic Energy Commission (PAEC) and are equipped with excellent facilities while the remaining are controlled by Provincial and Federal Governments and Private Sector.

vi) Health Care Under Social Action Programme
Social Action Programme aims at improving social services in priority areas, such as, primary health, nutrition, primary education, population welfare, water supply and sanitation. The central focus of SAPP-I was on strengthening policy-making and management capacity of the line departments and increasing allocation to social services. The Government's intent for SAP-II is to continue with the main agenda of SAP-I, but to focus on improving the quality of basic services, increasing community involvement and strengthening monitoring mechanisms. An important element of SAP-II is to undertake health sector reforms to bring systematic changes in the entire health sector. The SAP strategy for the sub-sector primary health is to improve quality and access of health services, rather expansion in physical infrastructure. Health component under the SAP focuses on promotional, preventive and rural services by giving priority to communicable diseases, including immunization and family planning in the basic health care. The financial allocation for the health programme under the SAP is Rs 14.0 billion or 20.8 percent of total SAP allocations of Rs 67.3 billion for 1999-2000. A more detailed discussion on SAPP strategies on health and other relevant issues are contained in Chapter-14.

Under the SAP, the physical targets likely to be achieved in the Primary Health Sector during 1999-2000 include: construction of 88 New Basic Health Units (BHUs), 50 Rural Health Centres (RHCs) and up-gradation of 54 BHUs and 36 RHCs, Immunization of about 14.81 million children under 5 year age, training of 3,458 Traditional Birth Attendants (TBAs) and training of additional 1,454 Lady Health Visitors (LHVs). In addition 1,920 nurses would be trained and about 8 Tehsil headquarter hospitals are to be established.

II. DRUG ABUSE

The drug addiction has recently emerged as a major health hazard, affecting the socio economic life of the nation. Thousands of productive youth have been rendered unfunctional by narcotic abuse. In view of the sharply upward trend in prevalence of drug abuse, it is considered a matter of high priority to educate the nation on the adverse effects of drug abuse.

Effective steps have been initiated by the Government for prevention of drug trafficking and drug abuse. A five years Drug Abuse Master Plan is under implementation. The project is aiming at poppy substitution in the poppy growing areas of NWFP. A mass awareness programme with allocation of Rs 4.0 million has been launched through the use of radio, news papers and pamphlets to inform and alert the general public of the necessity for community awareness and action. A community participation project for drug demand reduction, costing Rs 5 million has been initiated. An agreement for co-operation between Pakistan and Iran on the prevention of drug trafficking and drug abuse has been reached. A similar understanding has also been reached between Pakistan, Saudi Arabia, Egypt, China, Poland, Russian Federation and the Central Asian States. A "Rapid Situation Assessment" project on drug abuse has also been signed with the UNDCP. A strict ban on poppy cultivation has been maintained during the year and area under illicit poppy cultivation has been brought down through the implementation of area development crop substitution projects in the poppy growing areas of the NWFP and FATA. The jurisdiction of Anti Narcotic Force (ANF) 1997 has been extended to tribal areas and northern areas to deal effectively with the menace of drug abuse and drug trafficking. A three year programme mainly aimed at strengthening the drug law enforcement agencies, has been commenced and punitive actions have been taken against drug traffickers. The statistics regarding seizure of narcotics by the Law Enforcement Agencies during the year under review, is given in Table-12.5:

Besides, 10,011 Liters of Acetic Anhydride was seized during 1999. and assets of 26 drug traffickers amounting to Rs 212 million were frozen upto September, 1999.

III. NUTRITION

Malnutrition is a serious health problem in Pakistan. Infants, young children and women are identified, as a high risk group. At present, there is no simple solution to this health problem. However, strategies have been evolved to deal effectively with the specific nutrient deficiency diseases like goilre, anemia osteomalacia. In Pakistan, per capita per day calories intake is estimated at 2715 calories for 1999-2000. The intake of protein per capita per day is 71.03 grams. The national food intake balance sheet of six major food items including pulses, sugar, milk, meat, egg and edible oil, shows an improvement in case of milk (38.0%), meat (11.2%) and edible oil (3.3%) over last year while it has declined in case of pulses (-5.4%) and sugar (-5.0%). The annual trends of per capital food availability of basic food items, are given in Table-12.6:

T: Targets
E: Estimated
Source: Planning & Development Division

The Government has exhibited a very high sensitivity to nutrition problem and proposed a variety of remedial measures including food fortification, mass media nutrition education, new weaning foods and village level food processing. The following micronutrient deficiency control programmes have been undertaken during 1999-2000.

i) Iodine Deficiency Disorders (IDD) Control Programme
Production and marketing of iodized salt throughout the country continued during 1999-2000. As part of the Government policy, the private salt processors are being motivated to produce and market iodized salt . Promotional campaign through multimedia including radio and TV network and mass media continued during the period. The quality control system for iodized salt has been strengthened to improve the quality of iodized salt. A study to know the availability and awareness of iodized salt in Punjab had been completed and an the evaluation of the iodized salt programme supply side activities will be conducted during the year.

ii) Anemia Control Programme
A programme for anemia control through food fortification on pilot scale was initiated during 1999-2000. A field assessment of flour milling sector and quality control agencies has been conducted to develop a programme for iron fortification of wheat flour. The programme would be developed initially on pilot basis at two places. Expansion of Fortification of Wheat Flour Programme to country wide will be developed on the basis of experience gained during the pilot phase.

iii) Vitamin A Deficiency Control Programme
The fortification of edible oil/ghee with vitamin "A" is legislated since 1965, as part of Pure Food Rules, but standards of fortification are not adhered by the manufactures. Therefore, to strengthen the ongoing process, an assessment of quality control and technical operations for vitaminization of edible oil was conducted, so that the necessary technical support to oil manufactures and the quality control agencies could be provided to maintain the required level of fortification of vitamin "A". A programme for supplementation of vitamin "A" to the children has been launched by integrating it with National Immunization Days.

iv) Promotion and Protection of Breast-feeding
The programme on promotion of breastfeeding throughout the country is in progress. The baby-friendly hospital facility has been extended to more hospitals in all the provinces. Promotional activities remained in progress through multi-media campaign. The breastfeeding act would be finalized. The objective of the act is to rationalize production and marketing of infant formulas in the private sector.

A study on Baby Friendly Hospital Initiative (BFHI), Control of Diarrhoeal Diseases (CDD) and Acute Respiratory Infection (ARI) in Rawalpindi District was conducted to assess the overall situation with regard to CDD/ARI Programmes and BFHI.

v) National Nutrition Survey
A National Nutrition Survey has been planned, starting this year. The exercise is to assess the National Nutrition situation in the country, and macro and micro-nutritional status. This study will help in setting up a baseline information which will be used for formulating future programmes.

vi) Nutrition Programme SAPP-II
A national level programme for five years have been formulated to improve the nutritional status of the population especially vulnerable groups on sustainable basis. This project would strengthen institutions, the concerned line departments and involve NGOs and private sector to improve coordination and delivery of nutrition services to the vulnerable groups. The project will include programmes for combating micronutrient and protein energy malnutrition and improving food security and strengthening information, education and communication, institutional capacity and research. The provinces have also prepared similar comprehensive nutrition programmes. This programme will be funded out of SAPP-II (1997-2002).

vii) Prime Minister's Programme for Family Planning and Primary Health Care
The programme aims at extending outreach services to communities at their door steps through the Lady Health Workers (LHWs). These LHWs are a vital link between the community and the health facilities. They provide essential health services like reproductive health, MCH, health education, treatment of minor ailments, and referral of high risk cases to the health facilities. Main strategies of the programmes includes improvement in the quality of services, expansion of coverage through LHWs, better management and strengthening family planning and reproductive health components. The capacity of the LHWs in P.M. Programme was enhanced to deliver nutrition services to the mothers & infants, as well as, to deliver inputs and services for protection and management of breast feeding, elimination of micro-nutrient malnutrition e.g. Iodine Deficiency Disorders (IDD), IDA and Vitamin "A" deficiency, and counselling for benefits of mothers and young children.