Babar Tasneem Shaikh


Health indicators especially in the developing
countries have been improving gradually but too
slowly to be at par with the Millennium Development
Goals closing date. Pakistan in the community of
SAARC as well as EMRO countries has been
struggling to achieve a decent position vis-à-vis the
Neonatal Mortality Rate, Infant Mortality Rate,
U5Mortality Rate, Maternal Mortality Ratio,
Institutional deliveries, Maternal & Child Nutrition,
Contraceptive Prevalence Rate, Immunization
coverage etc. If analysed critically, all these issues of
public health come under the ambit of primary health
care. Decades ago, the movement of strengthening
primary health care echoed and pledged to consider
the local circumstances and available resources to
provide essential and appropriate health care at the
door steps of the community.1 Tackling these huge
challenges, any systems needs evidence base, rational
policy decisions and of course that follows just
resource allocation and pragmatic approaches to
achieve the desired results. Hitherto, the biomedical
research somehow has failed to create that needed
evidence base and therefore the paradigm shift
occurred in the world of health research, globally.2 It
has been oft-advocated to employ the innovative
research models and adopt new frameworks to study
the health seeking behaviours, health seeking patterns
and the determinants of health service utilisation,
particularly in the developing countries, where the
socio-cultural and economic scenario is quite diverse
and complex.3
Whether it is the John Snow’s story of
Broadway Street in finding the epistemology of
cholera or it is the philosophy of Virchow who corelated the incidence of tuberculosis with household
economics and the prevailing poverty in the society,
the primary determinants of disease are mainly
economic and social and therefore its remedies must
also be economic and social. The same school of
thought eventually is reflected in the millennium
declaration where poverty alleviation, improving
nutrition, literacy and women empowerment as the
mainstay for achieving the MDGs 4, 5 and 6.
Reiterating the main agenda, the WHO’s
Commission for Social Determinants for Health
presented three over-arching recommendations on
what needs to be done to reduce health inequities and
to close the health gap within and between countries:
improve daily living conditions; tackle inequitable
distribution of power, money, and resources; and
measure and understand the problem and assess the
impact of action.4
Today, people of Pakistan are suffering from
the worst of poverty: poverty of economics, poverty
of literacy and perhaps poverty of imagination.
Compounding on to this is the absence of a
responsive health system, which cares for dignity and
respect of the people and considers health a right of
all citizens.5 In this scenario, not having an equitable
access to the essential and basic healthcare, makes
them vulnerable to severe health shocks. The
rural/urban differentials make the picture even more
Prevalence of different categories of shocks (% of
all shocks faced by households)
Source: Government of Pakistan. Social Protection Strategy,
Planning Commission, Islamabad: 2007.
In the last 5 years alone, health shocks have
emerged to be affecting a large proportion of the
population in the country, even more than the natural
catastrophes which dismantled the whole agricultural,
water, livelihood and public infrastructure. The
researchers, managers, policy makers, development
partners and the civil society ought to understand that
disease focused approach will never deliver results. It
has to be a holistic approach underscoring all the
social determinants relevant to the context in order to
build a responsive and result oriented health system
to serve the vulnerable segments of our population.6
This system must be raised on the basic principles of
fairness and equity. More we have the social justice
in the society, more the health becomes apolitical and
accessible as a basic human right. If the picture is to
be turned around and reformed, the policies,
priorities, programs and interventions must consider
socio-cultural dynamics.7 Pakistan is at an important
juncture where decentralised form of governance is
being instituted. This is undoubtedly a more practical
opportunity for health sector (public, non-
J Ayub Med Coll Abbottabad 2011;23(3)
2 http://www.ayubmed.edu.pk/JAMC/23-2/Editorial.pdf
governmental, donors) to involve other entities such
as education, finance, planning, agriculture, women
development, water and sanitation, transport,
communication and social welfare to shoulder the
health agenda at the very local level. Logically, this
would be in line with the spirit of Alma Ata
Declaration, the Millennium Summit, and the
recommendation of Commission for Social
Determinants of Health. For Pakistan, this is the
perhaps time to refresh its pledges!

Full Text:



World Health Organization. Declaration of Alma-Ata.

International Conference on Primary Health Care. Alma-Ata.

National Institute of Health & Clinical Excellence and

Universidad del Desarrollo, Chile. Constructing the evidence

base on the social determinants of health: A guide. London:

Shaikh BT, Hatcher J. Health seeking behavior and health

services utilization in Pakistan: challenging the policy

makers. Journal of Public Health (Oxford) 2005;27(1):49–54.

Commission for Social Determinants of Health. Closing the

gap in a generation: health equity through action on the social

determinants of health. World Health Organization, Geneva:

World Health Organization. The World Health Report 2000.

Health Systems: Improving Performance. Geneva. 2000.

Shaikh BT. Understanding social determinants of health

seeking behaviours, providing a rational framework for

health policy and systems development. Journal of Pakistan

Medical Association 2008;58(1):33–6.

Borisch B. Working on the social determinants of health is

central to public health. Journal of Public Health Policy



  • There are currently no refbacks.

Contact Number: +92-992-382571

email: [jamc] [@] [ayubmed.edu.pk]