FBS survey:Health cover inadequate

By Zubeida Mustafa

THE PICTURE of the health sector as it emerges from the Federal Bureau of Statistics recently released report bodes ill for the country’s economic and social development.

This sector has traditionally been one of the most neglected ones although the state of the people’s health has a direct bearing on productivity, economic development and the cost of providing medical cover.

It is patent that the output of a sickly population is low as compared with that of a healthy people — more man-hours are lost because of illness, more people are required to maintain a given level of production and the expenditure on providing medical cover to the labour force is higher.

The implications of poor health for the social development and the quality of life of a people cannot be discounted either.

The “National Health Survey 1982-83” brings sharply into focus these aspects — that is if one cares to read into the meanings of the statistical tables spread over 158 pages. Since a similar survey on this scale — 11,000 households were covered — has not been conducted before in Pakistan, a comparative assessment is not possible.

It cannot be ascertained if the state of health of the people has improved over the years. The decline in crude death rate does not necessarily imply a lowering in the incidence of disease.

The most important factor to be taken note of is the prevalence of illness among the people. According to WHO, “Health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”

Deviations from this ideal may be regarded as morbid conditions. They range from minor indisposition causing little intereference with normal activity to the clearcut case of serious disability.

According to the Survey, 17 per cent of the population had suffered from some form of illness during one month prior to the interview. (To minimise the element of variations caused by seasons, the survey was staggered over four quarters). Significantly, morbidity was found to be higher in the rural areas, 18.2 per cent as against 14.3 per cent in the urban centres.

The inadequacy of health cover and poor living conditions in the countryside explain the greater prevalence of illness there. As a result, those sectors of the economy which are rural based, such as agriculture, are more adversely affected by the poor state of health of the people.

One aspect to be noted is the morbidity rate in different age groups. The incidence of illness is higher in people above 50 years of age and in children under four years. What is disturbing from the point of view of the productivity of the labour force is the pattern of morbidity. Good health appears to pick up at the age of 10. But in another 10 years the downward trend begins.

The morbidity rate shows a constant rise from the age of 20 onwards. In fact by the age of 40 it exceeds the national average. It is 19 per cent for the 40-44 years age group and goes up to 29.6 per cent in the 60-64 years bracket — the oldest segment of the labour force. In other words, the health of the labour force peaks out at the age of 20.

Another related factor is the morbidity rate among different professions. Illness is most prevalent in the agricultural and animal husbandry workers — 173.1 per 1000 employed persons. This, of course, is not a very satisfactory state of affairs for a country whose economy depends heavily on agriculture.

Priorities

The healthiest appear to be the clerical workers with a morbidity rate of 94.8 per 1000. The other occupations listed are sales workers 162, service workers 155, professional workers 151, production workers 137 and administrative workers 111 per 1000.

It also emerges clearly from the health survey that the lack of planning and misplaced priorities in the social sectors are making medical faciltiies inaccessible to the people. It is no occasion for self- congratulation for the health planners if the crude death rate has declined and life expectancy has gone up over the years. Simply sustaining life should not be the objective of the government’s health policy. The physical and mental well-being of people is equally important.

The high morbidity rate points to the failure of the government to create conditions conducive to healthy living. Two findings of the survey are significant in this context. First, the disease which has the highest incidence is shown to be malaria and other non-specified fevers — 41 per cent of all illnesses.

But it hardly needs to be pointed out that effective community health programmes, especially those directed towards promoting public hygiene and preventive medicine, can easily cut down the prevalence of these illnesses.

Secondly, the survey confirms that housing conditions have a direct bearing on the health of the population. People living in “pucca” houses and having access to piped water, gas/biogas/electricity and with flush toilets in their homes are less prone to illnesses than those who live in kuchcha dwellings, obtain water from wells and pumps, use cow dung and wood as fuel and who use closed pits or open spaces for disposal of waste.

The morbidity rates are quite revealing: pucca houses 155/1000 and others 177/1000, piped water 155/1000, wells 178/1000, and others 161/1000, gas, etc. 135/1000, cow dung, wood, etc. 161/1000 and oil 176/1000, flush toilet 142/1000, without flush 146/1000 and closed pit 183/1000. Given the government’s failure to provide adequate housing, potable water and fuel to the majority of the people, the poor state of health of the people is not unexpected.

Facilities

The FBS survey also underlines, in no uncertain terms, the lack of mass-orientation in the health policy. The paucity of government institutions and the high cost of medicare are clearly established.

While only 15 per cent of the people visited government hospitals, dispensaries and health centres, 42 per cent went to private hospitals/clinics 12 per cent to hakims, one per cent to homoeopaths and 15 per cent to compounders. Five per cent took self-medication and three per cent underwent no treatment at all when ill.

Even in the rural areas where private clinics are relatively scarce, 36 per cent went there. Only 16 per cent visited government institutions. The hakims and compounders saw 14 and 17 per cent of the ill people in the rural areas.

This pattern of treatment is explained by the distribution of the medical institutions in rural areas. Only one per cent of the villages surveyed were less than a kilometre from a public hospital and 69 per cent were more than 10 kilometres away.

The rural health centres and the basic health units are also not as widely dispersed as they should have been, the survey reveals. Only 11 per cent of the sample villages were within one kilometre radius of an RHC and 21 per cent villages from a BHU. Thirty-five per cent and 24 per cent are more than 10 kilometres away from an RHC and BHU respectively. But 28 per cent of the sample areas were within one kilometre radius of a private clinic and only 25 per cent were more than 10 kilometres away.

Inequities

This has logically pushed up the cost of treatment. According to the survey a family with a monthly income of less than Rs 300 was spending Rs 17 on health care. A household earning more than Rs 2500 per month spent Rs 168 on treatment. This points to the inequity which has resulted from the government’s failure to provide low cost health care to the population.

This inequity is even more pronounced between the rural and urban areas. The lowest income group spent Rs 18 on health, in the villages as compared with Rs 13 in the cities while the medical expenditure of a household in the most affluent group in the rural areas was Rs 211 as against Rs 149 in the urban areas.

Disparities between the provinces are also glaring. Sind is the most expensive province in terms of medicare whereas Baluchistan is the cheapest. It is clear that the growing dependence on the private sector has contributed to these inequities.

Source: Dawn 12 April 1986