Dr. Tauseefullah Akhund M.B.B.S, MPH (Sydney), (Australia)
Over past decades most countries around the world have seen widespread disparity in the society, wealth, race and gender. These disparities have affected the health status of the countries badly. Those countries which succeeded to keep the disparity under control eventually succeeded in improving the health of people. Some countries despite their huge economic growth failed to improve health and registered higher mortality in their population because of widened socioeconomic gap. Whilst some European countries have taken positive measures to reduce the inequality in their population, Pakistan has a very long way to go. Pakistan’s socio-cultural practice, religious influence, growing population and market driven policies to elevate its dooming economy have made a huge gap between rich and poor. It is the time for Pakistani government to take a holistic approach with inter-sector collaboration to curb this gap.
Health Inequalities in Pakistan is an important issue. There are several factors responsible for the inequalities in health, for example, social, economic, gender and age related factors. Social inequalities in health are healthgap in the population because of wealth, education, occupation, racial group, ethnicity, gender and rural or urban locality (Braveman, Starfield and Geiger, 2001). Persistence of communicable diseases in less developed countries and emergence of multi risk factorial non communicable chronic diseases in developed countries are mainly due to the inequalities in the health care access and system.
Socioeconomic factors top the reasons of health inequalities. It has been said that higher the socioeconomic status (SES), better the health. In this term, every high SES has better life expectancy than its next SES and poor are the worst sufferers. Studies carried out in Great Britain among the civil servants suggested that those who worked as grade 32 civil servants had better life expectancy than the grade 31 civil servants, who had better life expectancy than grade 30 workers (Navarro, 2004). Similar results were found in a study in Spain. According to Navarro (2004), researchers in Britain found that the most significant increase in life expectancy of British people was noted during Second World War. The most important factor for this surprising result was the reduction in the social gap between people. People from all the social classes united during the war and this in fact led to increase in the life expectancy. Although, this research did not clarify whether they considered the death of thousands of soldiers during war into account or not, those who survived lived longer. Navarro (2004) also suggests that after change of Britain’s policies that were more liberalizing caused reduction in the pace of increasing life expectancy of its people which strongly suggest the positive correlation between socioeconomic gap and health inequality.
Therefore, for a country to have good health, it is important that there should be minimum gap between rich and poor. Pakistan has very high religious and cultural influence on its people. According to the religious and cultural practices, people are divided into multilayer social status. In this multilayer social status system, higher status gets better treatment; by all the sectors including health. Sometimes, the privilege also goes to the religious groups. Pakistan has its majority of population living in rural areas. Most health care services and funding are often directed towards urban areas ignoring large chunk of rural population.
An age adjusted study carried out in Texas, United States to review the mortality of rural and urban population between 1990 and 2000 according to race, ethnicity and gender suggested that rural population suffered from most diseases including cancer, heart disease, diabetes, stroke, and respiratory diseases more than the urban population (McGehee, 2004). The study also suggested that black people suffered more death rates in metropolitan area, while Hispanic people had higher mortality in non metropolitan areas.
A cross-sectional survey carried out in Geneva, Switzerland between 1993 and 2000 suggests that many risk factors and chronic diseases like obesity, smoking, physical inactivity and high blood pressure are more prevalent among the low SES people as compared to high SES (Galobardes et al, 2003). If WHO capital (Geneva) hasn’t done up to the mark to remove gap of SES, no wonder Pakistan has long way to go. However, to wait until the developed countries come up with some strategy would be a wrong justification.
Pakistan is one of the poorest countries in the world. Many people live below the poverty line and can not access or afford the health care system. Rather, approaching health care comes at the bottom of their priorities way after food, house, and family and so on. An attempt by government to boost its dying economy led to changes which would adopt American markets. There is no doubt that this change has improved Pakistan’s economy, but rich have become richer and poor, poorer. This attempt has led to increase in the gap between rich and poor people. Many tertiary hospitals are built but only a few people can afford to access those services. There are many risk factors directly related to the poor economic conditions, like under-nutrition, poor housing conditions, poor sanitation, poor drinking water, difficult access to health care services, etc. All these lead to a multiple diseases like Tuberculosis, water born diseases, communicable diseases. Poor SES also leads to higher crime rate, homicide, suicide among youngsters causing a number of potential life years lost.
Economic disparity not only threatens public health, it also slows the economic growth. Mackenbach (2002) suggest that many economists consider economic gap in society as an indicator of poor health. He cites the Harvard graduate Kennedy and Kawachi who interpreted that the income inequality that occurred in U.S. in 80s and 90s led to long working hours, less time with family, increased crime rate, and eventually worsening the health and economic conditions of U.S.
Gender influence is another factor for health inequalities and mortality. Some of the diseases and health problems are confined to one particular sex. Pakistan has deep rooted religious practices and rituals which prevent the women to avail the access of many health services. Women are highly dependent on their husbands and family-in-laws for the health status. They should be accompanied by one male member of their families to go to the clinics; moreover critical decisions of total number of children in the family, family planning and termination of pregnancy are taken by their family-in-laws.
A high infant mortality and child death rates in Pakistan indicate health inequalities with age as factor. High infant mortality rate is a huge burden on health because it is responsible for maximum life year lost. This is not the case with only Pakistan. United States despite its economic boom in last two decades had rather widened the gap between rich and poor. This led to increase in the infant mortality rates in past two decades (Navarro, 2004).
The influence of socioeconomic and gender on health status of a person has been observed over years. W.H.O. in its Solid Facts (Marmot and Wilkinson, 2003) describes that higher socioeconomic gradient is one of the most important factors in a country’s and hence, a person’s health status. Whilst the government controlled health care system countries are working towards minimizing the socioeconomic gradient, market driven individualistic countries like US are also concerned about the importance of this gradient.
There are enough evidences which suggest that income inequalities are directly related to higher mortality; hence, only the economic growth of a country is not necessarily related to the improvement of a country’s health (Pearce and Smith, 2003). Many countries with higher gross domestic product (GDP) and gross national product (GNP) have a poor health conditions than some of the poor countries or states that have successfully minimized the socioeconomic gap. Countries like China and India state Kerala do not have the best of economies and yet, they have their health status quite comparable with the developed countries and have higher life expectancy (Pearce and Smith, 2003).
Nonetheless, for implementing a strong policy for equitable health services, growing economy of a country is vital. When most countries were successfully adopting policies to reduce inequalities in Europe, Finland could not implement its policy because of the recession in early 1990s (Mackenback and Bakker, 2003). Less developed countries like Pakistan need a holistic approach by its all government sectors to combat the inequalities and promote a policy for equitable health services.
The developed countries have started making policies which would reduce the socioeconomic gradients. Many European countries have started developing strategies to shorten the gap of SES to reduce the health inequalities in past one decade (Mackenbach and Bakker, 2003). Sweden, France and The Netherlands have adopted multiple policies which are targeted against the health inequalities. Improve child education, organize annual health checkups, improve employment opportunities are the part of these policies (Mackenback and Bakker, 2003). While European countries are trying to develop policies to reduce the socioeconomic gap between different classes, U.S. does not have any class layer system and its policies are targeted at reducing the income gap between different race and ethnicity (Rathore and Krumholz, 2004).
Ruger (2004) suggests that for a successful policy towards combating inequalities, the policy should not only emphasize socioeconomic determinants, but should take a holistic approach. First of all, the factors responsible for the increased socioeconomic gap should be determined and then the policy should be targeted to each of them. According to Ruger (2004), the orthodox health policies should be changed. Moreover, all the policies which affect the health policies indirectly or directly, including social and economic policies should be changed altogether. While some people suggest abolishing the multilayer hierarchy in the society simultaneously, others do not agree to this idea and suggest understanding the factors and political structure of a society and then working on them objectively (Ruger, 2004).
However, to make such solid policies, enough data and political will are essential. There are not enough data provided in Pakistan which would point at one particular disease mortality to the population inequality as its root cause. Frequently changing governments are the hindrance in making one solid policy. The influence of religion and religious practitioners is more on people than the politicians, which prevents the governments to take some strong actions against the rich and so-called influential people. Less developed countries like Pakistan highly rely on W.H.O. for the guidelines and policies of health and it is surprising the WHO itself is not very conscious for the issue of health inequalities. In the world health report 2000 the issue of population inequality in health is completely ignored. According to Braveman, Starfield and Geiger (2001) the world health report 2000 hasn’t measured the socioeconomic factors and other inequality issues within countries and hasn’t given any specific guidelines to make national policies.
Pakistan government has to take holistic approach to lessen the gap between rich and poor. The social, economic and health departments have to work together along with all the departments which indirectly affect the health of people. Policies should be made which would educate people and reduce the religious influence on people. Government should also make policies which guarantees employment to the most people. Moreover, rather than dragging towards Americanized market driven society, redistribution of wealth should be done to facilitate similar income range among all people. Women empowerment is an important thing in Pakistan. Removing inequalities from Pakistan would eventually push each government department into action for a holistic collaboration among them.
In the end, socioeconomic and gender inequalities are main disparities which affect the health of people. Some European countries have taken the initiatives and policies to reduce the inequality despite strong influence by liberal policies of U.S. Pakistan, which also adopts the liberal policies of U.S. to improve its economy has further widened its already big socioeconomic gap. A holistic and inter-sector approach to combat the ever rising inequality is needed for the betterment of health of people.
References:
Braveman, P., Starfield, B. and Geiger, J. (2001) World Health Report 2000: how it removes equity from the agenda for public health monitoring and policy. BMJ; 323: 678-681.
Galobardes, B., Costanza, M., Bernstein, M., Delhumeau, C. and Morabia, A. (2003) Trends in risk factors for lifestyle-related diseases by socioeconomic position in Geneva, Switzerland, 1993-2000: Health inequalities persist. American Journal of Public Health; 93 (8): 1302.
Mackenbac, J. (2002) Inequality, health and the economy. The Lancet; 360 (9347): 1794.
Mackenbach, J. and Bakker, M. (2003) Tackling socioeconomic inequalities in health: Analysis of European experiences. The Lancet; 362 (9393): 1409.
McGehee, M., Hall, S. and Murdock, S. (2004) Rural and Urban Death Rates by Race/Ethnicity and Gender, Texas: 1990 and 2000. Journal of Multicultural Nursing & Health. 10 (2): 13-23.
Marmot, M. and Wilkinson, R. (ED) (2003) Social determinants of health. The solid facts. (2nd Ed). World Health Organization: Europe.
Navarro, V. (2004) Inequalities are Unhealthy. Monthly Review; 56 (2): 26-30.
Pearce, N. and Smith, G. (2003) Is social capital the key to inequalities in health? American Journal of Public Health; 93 (1): 122-129.
Rathore, S. and Krumholz, H. (2004) Differences, Disparities, and Biases: Clarifying Racial Variations in Health Care Use. Annals of Internal Medicine; 141 (8): 635-638.
Ruger, J. (2004) Ethics of the social determinants of health. The Lancet; 364 (9439): 1092-1097.