• Babar Tasneem Shaikh


Health indicators especially in the developingcountries have been improving gradually but tooslowly to be at par with the Millennium DevelopmentGoals closing date. Pakistan in the community ofSAARC as well as EMRO countries has beenstruggling to achieve a decent position vis-à-vis theNeonatal Mortality Rate, Infant Mortality Rate,U5Mortality Rate, Maternal Mortality Ratio,Institutional deliveries, Maternal & Child Nutrition,Contraceptive Prevalence Rate, Immunizationcoverage etc. If analysed critically, all these issues ofpublic health come under the ambit of primary healthcare. Decades ago, the movement of strengtheningprimary health care echoed and pledged to considerthe local circumstances and available resources toprovide essential and appropriate health care at thedoor steps of the community.1 Tackling these hugechallenges, any systems needs evidence base, rationalpolicy decisions and of course that follows justresource allocation and pragmatic approaches toachieve the desired results. Hitherto, the biomedicalresearch somehow has failed to create that neededevidence base and therefore the paradigm shiftoccurred in the world of health research, globally.2 Ithas been oft-advocated to employ the innovativeresearch models and adopt new frameworks to studythe health seeking behaviours, health seeking patternsand the determinants of health service utilisation,particularly in the developing countries, where thesocio-cultural and economic scenario is quite diverseand complex.3Whether it is the John Snow’s story ofBroadway Street in finding the epistemology ofcholera or it is the philosophy of Virchow who corelated the incidence of tuberculosis with householdeconomics and the prevailing poverty in the society,the primary determinants of disease are mainlyeconomic and social and therefore its remedies mustalso be economic and social. The same school ofthought eventually is reflected in the millenniumdeclaration where poverty alleviation, improvingnutrition, literacy and women empowerment as themainstay for achieving the MDGs 4, 5 and 6.Reiterating the main agenda, the WHO’sCommission for Social Determinants for Healthpresented three over-arching recommendations onwhat needs to be done to reduce health inequities andto close the health gap within and between countries:improve daily living conditions; tackle inequitabledistribution of power, money, and resources; andmeasure and understand the problem and assess theimpact of action.4Today, people of Pakistan are suffering fromthe worst of poverty: poverty of economics, povertyof literacy and perhaps poverty of imagination.Compounding on to this is the absence of aresponsive health system, which cares for dignity andrespect of the people and considers health a right ofall citizens.5 In this scenario, not having an equitableaccess to the essential and basic healthcare, makesthem vulnerable to severe health shocks. Therural/urban differentials make the picture even moredesolated.Prevalence of different categories of shocks (% ofall shocks faced by households)Source: Government of Pakistan. Social Protection Strategy,Planning Commission, Islamabad: 2007.In the last 5 years alone, health shocks haveemerged to be affecting a large proportion of thepopulation in the country, even more than the naturalcatastrophes which dismantled the whole agricultural,water, livelihood and public infrastructure. Theresearchers, managers, policy makers, developmentpartners and the civil society ought to understand thatdisease focused approach will never deliver results. Ithas to be a holistic approach underscoring all thesocial determinants relevant to the context in order tobuild a responsive and result oriented health systemto serve the vulnerable segments of our population.6This system must be raised on the basic principles offairness and equity. More we have the social justicein the society, more the health becomes apolitical andaccessible as a basic human right. If the picture is tobe turned around and reformed, the policies,priorities, programs and interventions must considersocio-cultural dynamics.7 Pakistan is at an importantjuncture where decentralised form of governance isbeing instituted. This is undoubtedly a more practicalopportunity for health sector (public, non-J Ayub Med Coll Abbottabad 2011;23(3)2 http://www.ayubmed.edu.pk/JAMC/23-2/Editorial.pdfgovernmental, donors) to involve other entities suchas education, finance, planning, agriculture, womendevelopment, water and sanitation, transport,communication and social welfare to shoulder thehealth agenda at the very local level. Logically, thiswould be in line with the spirit of Alma AtaDeclaration, the Millennium Summit, and therecommendation of Commission for SocialDeterminants of Health. For Pakistan, this is theperhaps time to refresh its pledges!


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