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What about the differences?
A short overview of the health system in Pakistan and its
implications for immigrant health care in Norway
Commentary by Hammad Raza Syed og Nora Ahlberg
Sammendrag: For helsepersonell kan måten mange innvandrere forholder seg til tjenestene på virke uvant. Denne kommentarartikkelen bygger på refleksjoner gjort under et
feltarbeid for å samle medisinske data i Pakistan. Artikkelen forklarer pakistaneres tjenesteoppsøkende atferd ved å beskrive hvilke rammer pakistanske førstegenerasjons innvandrere har forholdt seg til i opprinnelseslandet. Helsesystemet i Pakistan presenteres,
hvordan det er bygd opp og hvordan og i hvilken grad folk flest bruker systemet. Legepasientrelasjonen diskuteres så vel som befolkningens forståelse av kroniske sykdommer
og oppfølging av behandling (compliance). Ifølge forfatterne resulterer økonomiske og
kulturelle rammer i helseoppsøkende atferd som er forkjellig fra den hos gjennomsnittspasienter i Norge. Også blant pakistanere som har innvandret til Norge kommer forskjeller i forventninger til og bruk av helsetjenestene til uttrykk. Forfatterne påpeker behovet
for bedre informasjon blant pakistanske innvandrere om hvordan det norske helsesystemet fungerer, slik at de skal kunne nyttegjøre seg tilbudet på linje med andre pasienter.
Flere momenter har i forfatternes øyne overføringsverdi når det gjelder andre innvandrergrupper fra den tredje verden.
Introduction
This commentary was written after a visit to Pakistan by one of the authors from December
2005 to March 2006. The objective of the visit was to collect data on lifestyle and psychosocial
factors of the population as well as gathering baseline information of their health status. The
plan was to compare this information with already existing data about the Pakistani immigrant community in Oslo. For this purpose it was decided to visit the district of Gujarat in
Pakistan. More than 90% of the Pakistani immigrants in Norway originate from this district.
The design of the study further encouraged us to focus on those villages of the Gujarat
district which in particular had contributed in sending immigrants to Norway. The following
villages were selected: Mundir, Buder Murjan, Mehmand Chak, Alam Pur Gondalan, Dilu,
and Jundawala.
The participants were recruited through various channels. They were informed about the
purpose of the health survey through announcements on loudspeakers in local mosques, by
posters on the busiest streets and through local political and administrative officers. Community opinion leaders such as Imams and school teachers as well as people working in the postal
department were also taken into confidence about the purpose and aims of the health survey.
Newspapers of large distribution in the area were used to advertise and to explain the purpose
of the survey. By these efforts we were able to secure the participation of more than 1600 per-
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sons above the age of 30 years living in the six villages. In other words, approximately 15% of
the total population of the villages responded to our request to take part in our health survey.
The design of the survey was modified according to local desires and socio-economic and
political conditions of these areas. A team of seven health workers were trained and employed
for this particular health survey. These health workers interviewed the participants and registered the information in questionnaires and also helped with anthropometric measurements.
The participants finally took part in medical consultations with one of the authors. During
consultation, measurements of fasting blood sugar of all the participants was performed. In
this way the author was able to give more than 1600 consultations in 3 months as part of the
survey. The survey provided a good opportunity to talk with many patients, general practitioners and health professionals working in the primary and specialist health services in Pakistan. This interaction brought about some thoughts of the health system of Pakistan and how
it might influence immigrants’ health care seeking behaviour in Norway.
Health facilities in Pakistan
The total number of hospital beds in Pakistan increased from 72.997 in 1990 to 93.907 in the
year 2000. Despite this 28% increase in hospital beds, the population per bed increased marginally by 1% – from 1.480 to 1.495. The otherwise significant increase in beds was neutralized
primarily by a previously unmatched increase in the total population which grew from 110
million in 1991 to 140 million in 2000, at the compounded rate of over 26% (Aslam, 2001).
Similarly, the number of registered doctors rose from 51.883 in 1990 to 91.823 in 2000, a
growth of 76%; dentists from 2.077 to 4.175 and nurses from 16.948 to 37.623. While the
ratios of population per doctor, dentist and nurse improved between 1990 and 2000, it still
remains high – one doctor per 1.529 inhabitants, one dentist per 33.626 inhabitants and one
nurse per 3.732 inhabitants.
Pakistan spends a negligible portion of its national budget on health and nutrition, just
0,7% of the GNP in 2000–2001. The total public sector expenditure on health and nutrition,
at the federal and provincial levels combined, was 24,2 billion rupees (Rs) in 2000–2001. Of
this Rs 18,3 billion, or 76%, went to meet recurring expenses leaving just Rs 5,9 million for
development (Aslam, 2001). In other words, only two dollars per capita are invested on health
in Pakistan per year (Easterly, 2001). The overall indicators of health are also very poor. Pakistan has an infant mortality rate of 76,53 per 1000 live births and the expected age at birth is
close to 62,3 years, with a minimal gender difference (Mughal, 2004).
From 1992 the Government of Pakistan had been trying to improve the country’s social
welfare system through the «Social Action Programme», which is based on national and international funding. It seeks to increase human development in four social sectors: elementary
education, primary health care, reproductive health and rural water supply and sanitation.
Although this programme has shown some signs of success in mobilizing effective resources,
its future depends on political stability and good co-ordination and planning between different donors and departments (Thornton, 2000).
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Pakistan’s health system
In Pakistan, prior to Independence in 1947 and until the 1960s the health care delivery system
was comprised of only civil hospitals and district council dispensaries. Most of the rural population had little access to basic health facilities and services. The second five-year plan (1960–
65) sought the establishment of 150 Rural Health Centres (RHCs) in West Pakistan over a
period of five years (Ali & Horikoshi, 2002).
Basic Health Units (BHUs) started in 1980 and during 1985–86 the Government decided
to establish one BHU in every union council. During 1991–92 the Government decided to
provide dispensaries in all larger union councils. At present there are 872 hospitals, 852
Maternal and Child Health Units (MCH), 514 RHCs and 5.155 BHUs throughout the country
(Ali & Horikoshi, 2002).
Health services in Pakistan are divided into primary and specialist care. The pyramid of
the public health sector consists firstly of BHUs each serving a population of 10.000–20.000
and RHCs each serving 25.000–50.000 people. Both BHUs and RHCs refer their patients to
Tehsil Hospitals (serving 0,5–1 million inhabitants). The next level of referral is District Head
Quarter Hospitals (DHQs) which constitute the tertiary level hospitals (serving 1–2 million).
At the apex of this pyramid system are the teaching hospitals (Karim & Mahmood, 1999).
Despite the efforts made by the Pakistani Government, poor utilisation of the primary
health care services has been reported. The main reasons for this poor utilisation has attributed to lack of physical accessibility as well as poor socio-economic status and cultural perceptions among the population, low literacy level of mothers and large family size (Shaikh &
Hatcher, 2005). According to one report by a leading donor agency the health sector in Pakistan is «infested with lack of efficiency, misallocation of resources, leakages, political influence, poor management and centralized financial, administrative and management
authority» (Mughal 2004).
To manage the prevailing flaws in the public health sector, the Government of Pakistan
presented a devolution plan in 2000. According to this plan districts have been given more
autonomy in all sectors, including health. The districts are now responsible for developing
their own strategies, programmes and interventions based on locally generated data and
locally identified needs. Following the principles of Alma Ata (Shaikh, 2006) the public health
care system is focused on primary care. At the community level, the Lady Health Worker
(LHW) programme of the Ministry of Health and the Village Based Family Planning Worker
programme of the Ministry of Population and Welfare have been established. These programmes have according to the Government gained an international reputation due to their effectiveness at the grass root level (Government of Pakistan & Ministry of Health & Ministry of
Population and Welfare, 2004).
The private health care sector is booming in Pakistan and consists of some accredited outlets and hospitals, but also many unregulated hospitals as well as a variety of unauthorised
practitioners, be they medical general practitioners, homeopaths, hakeems, traditional/spiritual healers, Unani (Greco-Arab) healers, herbalists or bonesetters (Karim & Mahmood,
1999).
The pharmacies in Pakistan are an important part of the private health sector. Pharmacies
in Pakistan are called «medical stores» and anyone can buy medicines from these stores without any prescriptions. The business is illegal, but the Government lacks resources to control
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it. For many people it is far easier buying medicines recommended at a medical store rather
than consulting a doctor for prescriptions. This is due partly to the easy physical access to
these stores, partly to the money saved in going to a «medical store».
The dynamics of obtaining treatment
Poverty in Pakistan is an increasing social problem. It is estimated that about 32% of Pakistan’s
population are below the food poverty line. The 1988 level was 26% (IUCNP, 2006). About
44% are below the poverty line on the human poverty index (UNDP, 2002). The implication
here is that a significant proportion of Pakistan’s population does not have adequate access to
food, basic services or opportunities. Moreover, 65% of Pakistan’s population live in rural
areas, where the bulk of Pakistan’s poor – about two thirds – are found.
These people who live in poverty do not perceive good health as a state of complete physical fitness. Rather, they define good health as being able to function at a level which does not
hinder them in performing their daily activities, especially those related to generating an
income. This concept of health does not correspond with the definition given by the World
Health Organization (WHO) which includes three dimensions: physical, mental and social
well-being. Poor socio-economic conditions not only define the meaning of health for poor
Pakistanis but also shape their pattern of health care seeking behaviour; Poor socio-economic
conditions compel them to explore all other alternatives before seeking any form of biomedical treatment. The poor rely on self-care, home remedies and consultations with traditional
healers. At least in the rural communities this is the dominant pattern. This health care seeking behaviour is rooted in the psychology of the population at large and is intimately linked
to cultural and social norms. For this reason even if a person or a family can afford to seek
proper treatment, it is almost socially or culturally mandatory to use remedies immediately
available to them as a first resort.
Such remedies are generally found in the close vicinity of the person seeking treatment.
They could be in the form of advice from family elders or some homemade substances available within the household. For example, in case of a fall or any musculo-skeletal injury, it is
common to massage the afflicted area with mustard oil. It might be possible that later one
would discover that an immediate surgical intervention was necessary to avoid complications.
Ignoring proper treatment could thus result in permanent damage. However, in Pakistani
society such unfortunate consequences would generally be accepted as a matter of fate.
The next phase of seeking treatment involves the «folk sector» in Pakistan. This phase
could involve consultation with any traditional spiritual healer or any person who is practising
alternative medicine. Poverty, combined with illiteracy and lack of knowledge about the pathological nature of illnesses, is the root cause for approaching a practitioner of traditional or
alternative medicine. The type and duration of symptoms also determine the choice of care
provider; In case of a mild single symptom such as fever, home remedies or folk prescriptions
are used, whereas with multiple symptoms and longer period of illness, a biomedical health
provider is more likely to be consulted (Sadiq & Muynck, 2001).
Another determinant of care seeking is the degree to which the symptoms of a disease are
socially and culturally acceptable. In Pakistani community social ties are strong and they have
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either positive or negative impact. A positive example would be when the afflicted person is
supported and cared for by family, close relatives and friends. Negative impacts are found in
cases where it is not socially acceptable to inform others about the nature of the disease or
disability. This is generally due to an ultimate fear of stigmatising one’s own close relatives.
In a Norwegian context the stigma which many Pakistanis associate with mental illness
could be one reason why Norwegian health workers are surprised by the reactions and behaviour of the families of the mentally ill. Some may try to hide the illness from others, some
may get over-involved in care giving and some may not seek medical advice at all because they
believe the illness is a sign that God has granted their relative special status (Karim et al.,
2004).
Another important characteristic of mental health services in Pakistan is related to the
overuse of the specialist services even for minor psychiatric illnesses: This possibly reflects
peoples’ wish to avoid the primary health services who are working in close community
networks.
Experiences from Pakistan
In Western countries it has been reported in various publications that the health status of
immigrant and ethnic minority groups is often worse than that of the population on average.
This vulnerability has been linked to low socio-economic status, poor psychosocial support
or negative experiences related to migration. It has been further suggested that minority
groups are at risk of not receiving the same level of health care regarding diagnosis, treatment
and preventive services which the majority population receives. It has also been thought that
health care services developed within a Western context are not adequately responsive to the
needs of non-Western immigrants.
To explore these issues we would like to discuss some of the experiences from Pakistan. A
brief account of these experiences would help to understand the health status of the people,
their understanding of health and their interaction with the health system.
Even though the survey data collected from Pakistan have not yet been analysed and exact
prevalence and percentages have to be calculated, we can report with confidence that an alarmingly high proportion of the participants of our local health survey in Gujarat were suffering
from some kind of somatic or psychiatric illness. The most commonly reported or observed
somatic ailments were related to diabetes, blood pressure, body pains and gastro-intestinal
problems. The most significant psychiatric symptoms were related to anxiety and depression.
Another important observation was the respondents’ inability to understand the severity of
their disease. On many occasions it was observed that participants who were suffering with
high blood pressure – as high as 200/180 mmHg or even higher – did not comprehend at all
the nature of their disease nor its complications. They did not express concern over their high
blood pressure levels. They were, however, all the more anxious to report and receive treatment for other bodily complaints related to it. Surprisingly, for most of the patients it was the
first time that somebody had diagnosed them as hypertensive.
Another significant observation was that while most of the participants were reporting
the chronic nature of their symptoms, they were not under any regular treatment or observa-
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tion. It was also observed that they changed care giver and likewise the mode of treatment
according to their subjective understanding of the illness at any given time and according to
advice from close relatives or friends. Types of treatment also varied with changing economic
circumstances.
In some cases I found that patients had started treatment with some cultural or household based remedies and then switched on to traditional/alternative treatment before finally
consulting a biomedical practitioner. One patient described this pattern in the following
words;
I thought my symptoms would go away with the well known remedies used in our family
for these sorts of body pains, but because they persisted and started interfering with my
daily routine I consulted the traditional healer. But that was of no help, so I decided to
seek treatment from a MBBS (biomedical practitioner) doctor. I got relieved, but that
was too expensive for me to continue.
Another patient explained his health care seeking behaviour in these words;
Since English medicines are very hot (a prevalent opinion about school medicines in
Pakistan, author’s note) and they have lots of side effects, therefore, I always try to cure
my symptoms by other ways of treatment, rather than to consult a medical doctor.
In Pakistan more than 80% of the child births take place at home (USAID, 2006). These deliveries are usually attended by traditional midwives – usually old women belonging to the
family or living in the local community. No formal education or training is required. The high
infant mortality rate reflect the difficulties associated with such deliveries. However, there are
no statistical figures that could explain the infant morbidity related to these home births.
The following account illustrates health care seeking behaviour after childbirth. A married couple came to visit at the survey camp with their 9 year old daughter. They said that their
daughter had been born at home with the assistance of one of the traditional birth attendants.
The traditional midwife had told them that their daughter was very weak at the time of birth
and noted that she took some time before she cried for the first time. The couple reported that
it was God who saved their daughter. They also described the first months of their daughter’s
life when she sometimes used to refuse nourishment. They thought that because of weakness
their daughter was not able to open her mouth or suck the milk. They mentioned several clinching of mouth episodes. To control this weakness of their daughter they were advised by their
elderly relatives that they should add honey to their daughter’s feed. But the episodic clinching
of mouth increased in intensity and become more frequent. They were advised then to consult
with a peer baba, a religious person who helps people with health and social problems using
holy knowledge. They had consulted the peer baba regularly for a considerable period of time.
Two years later they noticed that their daughter’s condition was worsening; The daughter had
started to faint while playing with other children. Only at that moment did they consult a
(biomedical) general practitioner. With the help of this doctor they went to a teaching hospital
where their daughter was finally diagnosed with epilepsy. Simply told this is a story of a birth
trauma to a child’s brain which over a period of 9 years ultimately causes epileptic fits. It is a
telling example of how disease is understood and the resulting health care seeking behaviour.
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Interaction
Making the consultation
In the Norwegian context, a consultation is considered to be a very organised and formal
meeting between a doctor and a patient. Making an appointment and being on time is regarded as all but compulsory, for both parties involved. In Pakistan, at least at the primary health
care level, no such formality of appointments or punctuality is required. What you need is
simply the information about the opening hours of a particular clinic or health care facility.
No queue system exists. Due to social and cultural reasons, however, children, women and
very sick patients have the priority in getting access to the doctor.
Usually, a consultation with a general practitioner does not require «closed premises», nor
does it require one to one interaction, as we experience it in Norway. Due to the non-existence
of the «closed room» consultation, it is quite possible that an ongoing conversation is overheard by the other patients or persons accompanying them. The concept of confidentiality is
quite different compared to what we observe in Norway. The only way to respect patients’
need for discretion is to control the volume of the conversation. While discussing serious or
intimate issues the patient and his/her doctor may create an imaginary closed space by
lowering their voices.
The consultations which this commentary is based on were conducted in open spaces,
such as back yards. Though not to the satisfaction of the doctor, participants of the consultation-survey were visibly quite comfortable with the situation. Even female participants seeking advice for gynaecological problems appeared at ease in this type of setting. It seems that
the economic situation of the country allows neither patients nor health practitioners to put
much priority to privacy-related issues.
The doctor-patient relation
The relation between a medical doctor and a patient in Pakistan is of a very special nature. In
a country where the total literacy rate is just 46%, among women as low as 26%, it is not surprising that a doctor is considered to be a supremely qualified person. People believe that a
doctor has a much wider perspective of life and knows «everything», not only with regards to
the medical profession but also with regard to matters of life in general. A doctor is considered
as one of the most important figures of society. For this reason doctors seemingly possess an
almost sacred and unchallenged authority over patients in Pakistan. Most patients take their
doctor’s advice very seriously. While a doctors’ advice is generally viewed with such high
respect, however, patients deviating from prescribed treatment is quite common. Such deviation are often related to the patient’s family related or socio-economic circumstances. The following statements reflect non-compliance with the doctor’s orders at different magnitudes.
One patient stated:
Yes, my doctor has advised me to go on a healthy diet earlier, but how can I follow his
advice when I have to take care of five other members of my family and my income is
limited? It is not easy to raise a family in Pakistan now, when everything is so expensive.
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Another patient said:
You know my medicines cost me 63 rupees per day. It is not possible for me to take medicines as prescribed by the doctor, but I take my medicines when I feel that my condition
is getting worse.
Communication and diagnosing
The art of communication between doctor and patient depends upon the patient’s assumption that a doctor knows everything about one’s illness, or that doctors have the capacity to
understand the illness from the symptoms described by the patient. This confidence may
explain patients’ satisfaction with their communication with their doctors despite short consultations, often limited to 2–3 minutes, and without proper clinical examination. Pakistani
doctors have obtained a lot of experience in diagnosing their patients from the described
symptoms without any diagnostic investigation. Diagnostic investigations are not a very
essential part of the primary health care services. Moreover, doctors are also well acquainted
with the additional economic burden they may place on patients if they advise them to take
clinical investigation in order to confirm their diagnosis. They use diagnostic services only if
they are not sure about their diagnosis or if they are confident that their patients can afford it.
Being a part of Pakistani society and trained in that society, doctors are quite confident of their
diagnosis based on symptoms and patients seldom exhibit any worries concerning the treatments advised to them based on the clinical understanding of the doctors.
In a European context it is looked upon with great skepticism for a doctor to communicate with the patients using patient’ relatives and family members as intermediaries. This is,
however, a common thing in Pakistan. The collective nature of society makes patients put
trust in family members acting as intermediaries, not doubting the sincerity of this type of
advocacy. Most of the time it is the most educated or outwardly oriented family member or
close relative who communicates with the doctor in order to explain the patient’s symptoms
effectively.
Chronic diseases and their understanding
In Norway we are quite concerned about the issue of chronic disease and the way it is conceived and understood among the members of the immigrant communities. It has been reported
in various studies that patients with immigrant background have little understanding of their
diseases and consequently they manage their chronic diseases poorly (Chowdhury & Lasker,
2002; Chowdhury, Lasker, & Mahfuz 2006; Lightstone et al., 1995; Mather, Chaturvedi, & Fuller, 1998). We tried to conduct observations on this issue and to discuss it with health professionals in Pakistan. Some statements might serve to illustrate:
Statement from a diabetic patient about his treatment routine:
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I usually do not take medicines because I do not think I need them regularly, but when I
am going to attend any party and I know that I am going to eat lot of food that I am not
allowed by my doctor, then I take my tablet.
A physician reported:
Patients consider diabetes, hypertension and other chronic diseases as they do a mere
headache or other such ailments. They believe that one course of medicine is enough to
cure these diseases. So they stop taking medicines when they feel themselves free of symptoms. They come back to us again only when they get new symptoms or complications
from the same disease. They are not able to make any connection between their new complications and the previous symptoms for which they have already consulted a doctor and
taken medicines.
Another physician reported:
There are many patients who consult us with somatic symptoms such as headache, body
pains or increased tiredness. We know that these symptoms could be eliminated or at least
reduced if the patients reconsidered their symptoms in the light of underlying mental
problems. We try to advise them, but they are not able to relate these symptoms with their
state of anxiety or depression because they do not understand that such diseases do exist
and cause symptoms. We explain to them, but when we feel that we are talking about
something which is beyond the imagination or understanding of our patients, we just
confine ourselves to prescribing medicines.
One patient of hypertension described his treatment regime in this way:
Once I consulted one specialist at the big hospital (teaching hospital), and I was prescribed medicines by that doctor. Those medicines were excellent and I got relieved of my
symptoms. Now I take good care of that prescription and whenever I feel dizziness or problems with my breathing I buy again the same medicines and those medicines still help
me.
Lesson learnt
This overview has been written hoping to provide Norwegian health personnel with some
background information on immigrant patients. It is a common belief that immigrants from
non-Western countries in general face difficulties in interacting with the Norwegian health
system. The difficulties are attributed to language barriers, interaction problems and differences in the concept of health and disease. Insufficient treatment because of varying concepts of
health is likewise a problem in Pakistan, as well as non-compliance due to financial reasons.
Neither health care professionals nor the patients we met in Gujarat were optimally satisfied
with this state of affairs. The reason for dissatisfaction among health care professionals ulti-
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mately resides in the lack of a welfare system in Pakistan. This clearly affects patients’ compliance; The treatment process is mainly focused on symptoms and no continuity or follow up
is observed for any kind of disease.
In Norway primary health services are actively involved in diagnosing patients’ symptoms
using the diagnostic methods available to them. These primary health services either continue
to treat the patient after securing a diagnosis or, if they feel that the patient requires more
advanced help, decide to refer the patient to the secondary health services for diagnosis and
treatment. In any case primary health services continue to play their part in further treatment
and prognosis. Western patients are generally well acquainted with this sequence. For most
non-Western immigrant patients, however, this is a new course of events. In many cases they
lose confidence and patience with the health services during the initial phase of contact with
the primary health care service. This might be due to intermediating diagnostic procedures
which might take some time before the actual commencement of the treatment process itself.
Moreover, in some instances non-Western patients experience difficulties coping with the
challenges posed to them by unfamiliar diagnostic methods and procedures. Although primary health services in Western countries succeed in making a diagnosis to the complaints or
symptoms, this has little influence on immigrant patients’ compliance to treatment.
There are two reasons for this lack of compliance. First, non-Western immigrant patients
usually have limitations in terms of their education, majority language proficiency and knowledge regarding the human body and the underlying mechanisms of disease. Secondly, they
are conditioned to use and interact with a different type of health system with a different working model and they bring that learnt behavior with them while interacting with the Western
health services. They behave according to their acquired cultural pattern of health seeking
behavior and compliance. This is the main reason why immigrant patients with a specific
diagnosis have been reported to have poorer control and more complications than the majority populations in most of the Western countries (Chowdhury & Lasker 2002; Chowdhury,
Lasker, & Mahfuz 2006; Lightstone et al., 1995; Mather, Chaturvedi, & Fuller, 1998). Moreover, in the Western countries patients have become active in pursuing their treatment process, whereas most non-Western immigrants are used to interact with their respective health
systems as passive recipient of health services. This attitude combined with comparatively
poor socio-economic conditions of non-Western immigrant patients is a source of considerable burden to the established welfare societies. This burden may be identified by high levels of
sick leaves, unemployment and premature pensions reported for most of the immigrant
populations in the Western welfare states.
It is, therefore, important to think about how we can integrate immigrant communities
into our health care systems. One important step towards this goal could be achieved through
effective provision of information to these communities about the existing health services and
other related facilities in Norway. There is a need to develop comprehensive information strategies tailored according to patients’ cultural backgrounds. A better understanding of the
health system and its working model will empower immigrant communities to come in contact with the health system and also improve the mutual state of confidence and trust between
them. Furthermore, an increased level of interaction will help to reduce existing inequities in
health and disparities in the use of health services.
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