Budget and health sector: low allocations, poor achievement

By Zubeida Mustafa

IT IS a measure of the government’s poor commitment to public health that one of the largest cuts instituted in the revised Federal ADP now announced is for this sector.

From Rs 810 million, the allocation for health has been scaled down to Rs 736 million, which is considerably less than what was spent in 1986-87. The health sector will receive less this year in the Sind ADP too, the allocation having been reduced from Rs 364.6 million in 1986-87 to Rs 360.6 million in 1987-88.

Low-04-07-1987The low priority accorded to health in government spending points to lack of foresight and social commitment. After all, the productivity of a people and their quality of life is determined among other factors by the state of their health and the medical care available to them.

Moreover, Pakistan is committed to the WHO goal of health for all by 2000, but it is still far from fulfilling the criteria the UN agency has laid down.

Low allocation:  The federal and provincial budgets announced in June do not present a very robust picture of the health sector. The total allocation for health in 1987-88 is Rs 6.8 billion.This is no doubt a 20 per cent increase over last year’s. But in 1986-87 the increase was much higher at 28 per cent. It was 26 per cent in the preceding year.

Pakistan’s allocation for health in 1986-87 worked out to 0.9 per cent of the GNP which is nowhere close to the WHO prescribed standard of five per cent. Hence it was logical to expect a bigger increase in 1987-88.

Another disquieting feature of the health allocation this year is the distribution of resources between the development and non-development budgets. Nearly 56 per cent of the total allocation, that is Rs 3.8 billion, will go towards meeting the recurring costs. That would not leave many resources for the expansion of health facilities.

In fact the government’s failure to expand health care adequately during the Sixth Five Year Plan period is underlined by its inability to mobilise as much fund for the development of the health sector as was provided in the Plan. Of the Rs 13 billion earmarked for health, just Rs 10.9 billion (84 per cent) would have actually been spent by June 1988. Not surprisingly many of the physical targets of the Plan will not be met either.

The low achievement in some subsectors until June 1987 when only one year of the Plan period was left to go is most appalling, as the table that follows shows.

There are three aspects of the health sector which call for special mention.

  • First, development has not been uniformly spread in all the subsectors. While the urban areas which already have a higher ratio of facilities have received great attention, the rural areas have lagged behind. Ironically, the underdeveloped countryside is in need of infusion of more resources so that a health infrastructure can be built. Neglect of the rural sector manifests itself in the poor achievement rates for the rural health centres, the basic health units and the paramedics. Since hospitals and nurses are concentrated in the cities their number has grown at a faster pace. The authorities now acknowledge that the coverage of the rural areas is inadequate and the rural service outlets have \originally planned,
  • Secondly, the problem of unemployment among doctors has not been adequately resolved. Nearly 6,500 posts were said to have been created last year but that would have still left thousands of doctors jobless. As many more join their ranks every year, the number of unemployed doctors goes on swelling. It is clear that an ad hoc approach is not the answer. A planned expansion of the health services is needed to absorb the doctors who graduate every year. Ideally, the number of seats in the medical colleges should be related to the needs of the health system which in turn should be geared to the needs of the population. Since the health care facilities are not growing as fast as they should, there has been a glut of doctors in spite of the fact that the ratio of doctors to the population is still very poor. So far the government has tackled the problem by reducing the seats in the medical colleges, expanding the private sector by providing it new incentives and creating some posts as a stop gap measure. But this approach is not the most appropriate to meet the health needs of the masses. While it will make health care more expensive, it can also result in a lopsided expansion of the health services.

Primary care

  • Thirdly, the government has concentrated its efforts in one area but failed to make much progress in others. As a result, its achievement in one subsector could be neutralised by its failure in another. For instance, the success in the immunisation programme of children is remarkable. By next year the target is expected to be exceeded. But not much has been done in the field of primary health care especially in improving living conditions of the people. Thus 56 per cent of the people — 72 per cent in the rural areas — do not have access to clean drinking water. Nearly 81per cent of the people — 95 per cent in the villages — have no sewerage facilities. As a result many of the children who will be saved from death by any of the six communicable diseases of childhood could still die of other ailments such as malaria, typhoid or water-borne diseases. Even the mass production of ORS which has already exceeded the Sixth Plan target does not ensure that it is actually used by mothers for infants suffering from diarrhoea. Besides in many illnesses ORS by itself is no cure but requires follow-up medical treatment which might not be forthcoming in the rural

In the case of doctors, dentists and hospital beds the Sixth Plan targets of population per facility has already been achieved (according to official claims). But it is not known whether the health profile of the population has changed.

Since the current mortality rate, infant mortality rate and the expectancy at birth have not even been revealed there is no way of assessing the progress, if any, in the health sector.

This is however certain that increase in quantity has been accompanied by a marked deterioration in the quality of the services and facilities available.

Source: Dawn 04 July 1987