Sunday, March 10, 2013

Pakistan Fares Marginally Better Than India in Health Study

Pakistan ranks in the middle among 15 similar countries compared by the Global Burden of Disease Study 2010 (GBD 2010).  Other countries in this group include India, Djibouti, Kyrgyzstan, Laos, Moldova, Mongolia, Nicaragua, Palestine, Papua New Guinea, Philippines, Solomon Island, Uzbekistan, Vietnam and Yemen.

Source: Global Burden of Disease (GBD) Study

 The study is  is a collaborative project of nearly 500 researchers in 50 countries led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. The Institute describes it as " the largest systematic scientific effort in history to quantify levels and trends of health loss due to diseases, injuries, and risk factors. GBD serves as a global public good to inform evidence-based policymaking and health systems design".

In terms of the number of years of life lost (YLLs) due to premature death in Pakistan, the study found that lower respiratory infections, neonatal encephalopathy (birth asphyxia and birth trauma), and diarrheal diseases were the highest ranking causes in 2010. Of the 25 most important causes of burden, as measured by disability-adjusted life years (DALYs), diarrheal diseases showed the largest decrease, falling by 35% from 1990 to 2010. The leading risk factor in Pakistan is household air pollution from solid fuels. Interpersonal violence, including crime and terrorism, is ranked 20th on a list of  71 causes of premature mortality in Pakistan.

Leading Mortality Causes in Pakistan

Recent research shows that there are potentially far reaching negative consequences for nations carrying high levels of disease burdens causing lower average intelligence among their current and future generations.

World IQ Map

Published by the University of New Mexico and reported by Newsweek, new research shows that there is a link between lower IQs and prevalence of infectious diseases. Comparing data on national “disease burdens” (life years lost due to infectious diseases or DALYs) with average intelligence scores, the authors found a striking inverse correlation—around 67 percent. They also found that the cognitive ability is rising in some countries than in others, and IQ scores have risen as nations develop—a phenomenon known as the “Flynn effect.”

According to the UNM study's author Christopher Eppig and his colleagues, the human brain is the “most costly organ in the human body.” The Newsweek article adds that the "brainpower gobbles up close to 90 percent of a newborn’s energy. It stands to reason, then, that if something interferes with energy intake while the brain is growing, the impact could be serious and longlasting. And for vast swaths of the globe, the biggest threat to a child’s body—and hence brain—is parasitic infection. These illnesses threaten brain development in several ways. They can directly attack live tissue, which the body must then strain to replace. They can invade the digestive tract and block nutritional uptake. They can hijack the body’s cells for their own reproduction. And then there’s the energy diverted to the immune system to fight the infection. Out of all the parasites, the diarrheal ones may be the gravest threat—they can prevent the body from getting any nutrients at all".

Looking at the situation in South Asia, it appears from the WHO data that Pakistan is doing a bit better than India in 12 out of 14 disease groups ranging from diarrhea to heart disease to intentional injuries, and it is equal for the remaining two (Malaria and Asthma).

Another detailed WHO report on World Health Statistics for 2010 assesses and compares its member nations on the basis of nine criteria including mortality and burden of disease, cause-specific mortality, selected infectious diseases, health service coverage, risk factors, health workforce-infrastructure, health expenditures and demographic and socioeconomic statistics. It shows that both India and Pakistan have some serious challenges to overcome to have any chance of meeting health-related Millennium Development Goals (MDGs 4, 5 and 6).

Related Links:

Haq's Musings

India and Pakistan Suffer Heavy Disease Burdens 

India and Pakistan Off Track, Off Target on Sanitation

Pak Lady Health Workers "Best in the World"

India's Air Most Toxic in the World

Infectious Diseases Kill Millions in South Asia

WHO Says Pakistan On Track to be Polio Free


Iqbal Singh said...

In the Human Development Report of 2013, the Health Index for India is 0.722 edging out Pakistan at 0.721. I believe, historically, Pakistan was ahead of India but no longer.

Riaz Haq said...

An excerpt from the HDR 2013 report summary mentioning Pakistan is as follows:

More than four-fifths of these developing countries increased their trade to output ratio between 1990 and 2012. Among the exceptions in the subgroup that also made substantial improvement in HDI value are Indonesia, Pakistan and Venezuela, three large countries that are considered global players in world markets, exporting or importing from at least 80 economies. Two smaller countries whose trade
to output ratio declined (Mauritius and Panama) continue to trade at levels much higher than would be expected for countries at comparable income levels.

Here's a Business Standard report on HDI 2013 in South Asia:

Of 187 countries, India's Human Development Index (HDI), essentially a composite measure of health, education and income, rank stands at 136, on a par with Africa's Equatorial Guinea and just above Cambodia and Laos in Southeast Asia. Even over a longer period (between 2000 and 2012), it registered average annual HDI growth of 1.50 per cent, lower than Pakistan's (1.74 per cent).

Viewed in the context of the BRICs grouping (Brazil, Russia, India and China), India's standing is much below its peers - China is ranked 101st, Russia 55th and Brazil 85th. In fact, India remains squarely stuck at the bottom end of the second-lowest category in the report -Medium Human Development - even as neighbour Sri Lanka (99) moves a step higher towards becoming a "high human development" nation.

A closer look at India's performance reveals more inadequacies, especially in education. Though the country's life expectancy at birth, mean years of schooling and per capita GNI are comparable to peers, India's "expected years of schooling" is significantly below others, including Vietnam, Bhutan and even Swaziland.

Gender inequality
India is no easy country for women. The Human Development Report's Gender Inequality Index, which assesses gender-based inequalities based on reproductive health, empowerment and economic activity, ranks India 132nd out of 148 countries, below Bangladesh (111) and Pakistan (123).

"26.6 per cent of adult women have a secondary or higher level of education, compared to 50.4 per cent of their male counterparts (in India)," said an explanatory note. "Female participation in the labour market is 29 per cent, compared with 80.7 per cent for men."

Difficult future?
Though the report recognises key initiatives undertaken in India in recent years - particularly reforms in the education system, the direct cash transfer programme, a rise in social sector spending, public-private-partnerships across sectors and growing connectivity -vital concerns remain.

"India has the most projected child deaths over 2010-2015, about 7.9 million, accounting for nearly half the deaths among children under five in Asia," the report said. "China has more people than India, but is projected to have less than a quarter (1.7 million) the number of child deaths over 2010-2015."

India also has to contend with a substantial, uneducated population, possibly partly counteracting the country's feted demographic dividend. "Despite the recent expansion in basic schooling and impressive growth in better educated Indians, the proportion of the adult population with no education will decline only slowly," the report predicted.

"Even under an optimistic fast-track scenario, which assumes education expansion similar to Korea's, India's education distribution in 2050 will still be highly unequal, with a sizeable group of uneducated (mostly elderly) adults."

Riaz Haq said...

Mahesh: "The title of your blog is about health being marginally being better in Pakistan but @ Singh indicates that has changed. I think both countries need to improve but your response seems out on left field."

The GBD is a comprehensive and focused study dealing with burdens of disease in each country. I trust it as more reliable than a single composite figure as health index offered by HDR. Read the two to get a sense of it yourself.

Riaz Haq said...

Here's Daily Times on more midwives for Pakistan:

Speakers at the second annual conference on Maternal and Newborn Health Programme have stressed the importance of research-based evidence to improve policies and practices related to maternal and newborn health in Pakistan.

The conference was held on Thursday, with the theme ‘Bridging the Gap – Evidence for Policy and Practice’. Findings and lessons from projects funded by Research & Advocacy Fund (RAF) were presented. Sessions focussed on the cost and financing of maternal and newborn health in Pakistan, socio-economic and cultural factors affecting maternal and newborn health and engaging with civil society to improve health outcomes.

Delegates from both the public and private sector, including provincial secretaries and director generals of health and heads of various national and international NGOs attended the event.

Planning Commission of Pakistan’s deputy chairperson, Dr. Nadeem ul Haq hoped the commission will learn from the research findings from RAF work.

Peter Upton, Director British Council, Desmond Whyms, Senior Health Advisor UKaid, Andrew Mackee, Acting Counsellor Development Cooperation AusAID and Sarah Hall, Programme Manager RAF also addressed the audience, stressing the respective commitments of their organisations to remain engaged in improving Pakistan’s health outcomes. The speakers highlighted the purpose of RAF, and stressed the need to share knowledge, information and strengthen collaboration between national, provincial and local public and private stakeholders to work together to improve maternal and newborn health in Pakistan.

“Women and children are the UK’s number one health priority in Pakistan” said Desmond Whyms. He claimed that by 2015, UK aid would have funded the training and deployment of 12,000 community based midwives, helped prevent the death of 3,600 mothers, delivered 350,000 more babies in hospitals and provided full immunisation for 280,000 children.\03\22\story_22-3-2013_pg11_3

Riaz Haq said...

Here's a story of how Lahore fought dengue outbreak in 2011:

..“No one expected this kind of political commitment,” said Qutbuddin Kakar, who oversees programmes to combat malaria and dengue in Pakistan for the World Health Organization (WHO). “In this part of the world, at least, we had not seen this kind of response before.”

The anticipated 1,000-plus deaths did not occur, and since then, dengue fever cases have dropped - 200 in the province (Punjab) last year, without any reported deaths.


The results they collect are processed on site by specially-designed Android based applications on their smartphones, and uploaded to a centralized dengue prevention centre.

There, analysts match the entomological data with reports from hospitals showing where dengue patients are being treated. Based on the findings, a team is sent to fumigate areas where aedes mosquitos seem to be breeding and infecting people, or to identify and remove sources of standing water.

The key season for infections comes with monsoon rains, when the aedes aegyptus and aedes albopictus mosquitoes, which can carry the virus, begin to appear.

Chronology of an outbreak

In August 2011 heavy monsoon rain dumped 13 inches in a week, leaving parts of Lahore with large bodies of standing water, and raising immediate concerns about disease.

By mid-October, the provincial government in Punjab reported that more than 11,000 dengue cases were recorded by the provincial government.

“It was an exponential increase in number, and it really frightened the government,” said Faran Naru, a consultant hired by the provincial government to tackle the problem. “And the issue was resonating in the media... so it created a panic in the public which had to be contained.”

Most people infected with dengue recovered on their own, said Naru, but once media outlets began reporting on the extent of the outbreak, thousands showed up at hospitals and laboratories to get tested.

An initial team of 70 entomologists conducted 12,000 spot-checks to track where aedes mosquitos were present. By mid-October, this data had been mapped, along with the locations of 11,000 reported dengue patients.

The results surprised the scientists. The worst affected areas were some of the wealthiest neighbourhoods of Lahore: Model Town, Race Course, Mozang, and Gulberg.

“I saw that in Model Town there is a big park, and in Race Course there are two of Lahore's biggest parks… and I believe lots of breeding was happening there and mosquitoes were leaving from there and infecting people,” said Naru.

The mosquitoes need fresh water to lay their eggs, and the large puddles in Lahore's biggest public parks proved to be ideal homes.

Another hotspot was the Mozang neighbourhood, home to one of Pakistan's largest graveyards. The 150-acre area was found to be a major breeding ground for mosquitos. Gravediggers had dug large pits to hold water, which they used to soften the dirt when digging.

“It's fresh water,” said Naur, “from the tap, and there were 70 pits, and all of those were infected, full of larvae.”

Back in the hospital, dengue patients were separated into special areas for treatment. The home of each dengue patient was fumigated, along with 12 surrounding houses, three in each direction.

Sanitation workers unclogged sewers and drains in an effort to clear areas of rainwater; and parks, gardens, and cemeteries were also sprayed. Thousands of Mosquitofish and Garden Carp - fish species known to attack mosquito larvae - were also released into ponds and ditch canals.

Within a few weeks, entomologists detected far fewer aedes mosquitoes, and the prevalence of dengue cases rapidly decreased.

Riaz Haq said...

India accounted for three of every five new leprosy cases worldwide last year, or 134,752 of the 232,857 cases reported globally, the Geneva-based WHO said in an Aug. 30 report. New cases have increased annually from an historic low of 126,800 in 2010, yet remain well below the 560,000 recorded as recently as 2000, thanks to the effectiveness of multidrug therapy.

Riaz Haq said...

How #Pakistan’s National Health Insurance Program Will Work via @WSJIndia

Pakistan’s government launched a national health insurance program for its poorest households Thursday, marking the start of the most-ambitious public health project in the country’s history.

The Prime Minister’s National Health Program will from Thursday cover families that make less than $2 a day through a gradual rollout. In the first phase, over 3 million families will get health insurance in 23 districts, with the ultimate aim to cover 22 million households across the country, officials said.

“This is another step towards the welfare state that we promised to create when we came into power,”said Pakistani Prime Minister Nawaz Sharif.

The Pakistani government already subsidizes health care to varying degrees in public hospitals, but officials acknowledge these facilities are unable to handle the patient load or achieve public health targets.

The government said earlier this year that it wouldn’t be able to meet the United Nation’s targets for child and maternal mortality rates that formed part of the Millennium Development Goals, which had a deadline of 2015. Critics have blamed Pakistan’s low health spending and inadequate management as key factors in the poor health provision. Between July 2014 and March 2015, Pakistan spent just 0.42% of its GDP on health. The U.S. government spends about 8.3% of GDP on healthcare.

The new insurance program will cover treatment at both public and private hospitals. Private hospitals that sign up will then be offered loans on easy terms to upgrade their facilities, officials said, without providing further details about interest rates and conditions.

Saira Afzal Tarar, minister of state for health Services, regulations and coordination, said most Pakistanis pay out of pocket for treatment. “There is treatment at government-run hospitals, but there are long lines. Those who don’t have a recommendation have to wait months for treatment,” Ms. Tarar said at the launch ceremony in Islamabad. “With this [health insurance] card, you’ll be able to go to the hospitals where you weren’t allowed to even go to the front door. Now, you’ll be treated there with dignity and respect.” Ms. Tarar said.

The national health program, with an initial funding of 9 billion Pakistani rupees ($86 million) will pay for the treatment of the types of illnesses identified by the government as critical: heart disease, diabetes and related illnesses, cancer, kidney and liver diseases, complications from infections like HIV and Hepatitis, road accidents, and burn injuries. Officials said coverage can be extended to other conditions considered life-threatening.

The government said Thursday that the program will be run in partnership with provincial governments, which will share the financial burden. Beneficiaries will receive insurance cards, after selection from a database of low-income Pakistanis set up in 2008 for a separate cash support program.

The coverage includes 50,000 rupees for general treatment, and 300,000 rupees for serious illnesses. Mr. Sharif said on Thursday that the government is making arrangements for an emergency fund that would extend coverage to 600,000 rupees for cases that require longer treatment.

Officials on Thursday didn’t provide specific timelines for the rollout of the next phase, which is expected to cover another 3.3 million households. The finance ministry said earlier this year that the program aims to cover 22 million families.

The finance ministry, quoting World Bank data and 2008 population estimates, said last year that if living on $2 a day is taken as the poverty line, over 60% of the population would fall in that category.

Riaz Haq said...

Among peers and neighbours India is performing the worst when it comes to the health of its citizens. Whether it is life expectancy, mortality due to all causes, under-five mortality or mortality among men and women between 15 and 49 years, on most counts, India ranks way below China, Brazil and Sri Lanka, just below Bangladesh and Nepal and in some cases even Pakistan.

This was revealed in the Global Burden of Diseases, Injuries, and Risk Factors 2010 Study (GBD 2010), a collaborative project led by the Institute for Health Metrics and Evaluation (IHME) at the University of Washington. The study details the causes of death and disability — across age groups and genders — for 187 countries around the world.

Riaz Haq said...

How bad are most of #India's medical schools? Very, according to new reports. #highereducation #health #MEDICINE

In a country with the world's heaviest health burden, and highest rates of death from treatable diseases like diarrhea, tuberculosis and pneumonia, corruption at medical schools is an extremely pressing issue. The Indian Medical Association estimates that nearly half of those practicing medicine in the country do not have any formal training, but that many of those who claim to be qualified may actually not be.

a couple of recent studies and reports have cast serious doubts on the quality and ethics of the country's vast medical schooling system. The most recent revealed that more than half of those 579 didn't produce a single peer-reviewed research paper in over a decade (2005-2014), and that almost half of all papers were attributed to just 25 of those institutions.

The 2011 court case against a man, Balwant Arora, was one of the earlier indications of the massive levels of fraud. Arora brazenly admitted to issuing more than 50,000 fake medical degrees at around $100 apiece from his home, saying that each of the recipients had "some medical experience" and that he was doing it in service to a country that desperately needs more doctors. He had served four months in jail in 2010 for similar offences.

Private medical colleges have proliferated rapidly in India. When in 1980 there were around 100 public colleges and 11 private, the latter now outnumber the former by 215 to 183. Most are run by businessmen with no medical experience. Last January, the British Medical Journal found that many private medical colleges charged "capitation" fees, which are essentially compulsory donations required for admission. Jeetha D'Silva, who authored that report, wrote, "Except for a few who get into premier institutions of their choice purely on merit, many students face Hobson's choice — either pay capitation to secure admission at a college or give up on the dream of a medical degree."

The best public medical colleges have acceptance rates that are minuscule, even compared to Ivy League universities. Those colleges also tend to be the ones that produce the most research papers, as well as handle the most patients, which would seem to eliminate the possible excuse that overwhelming patient burdens prevent private colleges from producing valuable research.

The most productive medical college in India is also its largest public health institution, the All India Institute of Medical Sciences, or AIIMS. In the 10-year period that Samiran Nundy and his colleagues examined, AIIMS published 11,300 research papers. For context, that is about a quarter of what Massachusetts General Hospital produced in the same time frame.