Amimah Fatima Asif Healthcare Challenges In Gilgit Baltistan

Review Article

HEALTHCARE CHALLENGES IN GILGIT BALTISTAN: THE WAY FORWARD

Amimah Fatima Asif1

1
Lady Medical Officer, District Headquarter Hospital, Skardu, Gilgit Baltistan.
Correspondence: Amimah Fatima Asif . Email: [email protected]

Abstract

Quality healthcare delivery is the bedrock to exponentially accelerate the development of a country. Unfortunately, in
Pakistan healthcare has been neglected since a long time, with the common man bearing the brunt of this acute
situation. There are critical challenges in health care, with paucity of trained human resource and deficit of regulated
infrastructure and service delivery being the predominant dilemmas. Primary and secondary healthcare are in an
unseemly state, to say the least. Maternal and child health care, accident, and emergency departments and mental
health are among the most undermined and forsaken areas of healthcare, primarily in the far flung Gilgit Baltistan
region of Pakistan. The only way forward is if the political regime, administration and the medical personnel work in
concurrence to revise the health infrastructure of the country.

Introduction week) preventive Maternal, Neonatal and Child Health

The Northern Areas of Pakistan were re-designated as (MNCH) services due to deficiency of one or more
Gilgit Baltistan (GB) under the Gilgit Baltistan components of preventive MNCH services package.
Empowerment and Self Governance Ordinance 2009. Similarly the RHCs and CHs were assessed for
Gilgit Baltistan now holds the status of an autonomous provision of 24/7 (24 hours a day, 7 days a week) Basic
territory of Pakistan. The people of GB are a pristine Emergency Obstetric and Newborn Care (EmONC)
example of ensuring survival against challenges service package and for additional complementary
imposed by nature and worldly circumstances. They are services, none of them were fully functional and were
an amalgam of various Islamic sects cohabiting in unable to provide complete package of basic EmONC
harmony, enduring harsh winters, enjoying pleasant services. Likewise in all DHQ hospitals due to lack of one
summers and hosting throngs of tourists from all over the or more of the essential components, none of the DHQ
world. These people have homes amongst the three hospitals were completely functional for provision of 24/7
largest mountain ranges of the world; the Karakoram, Comprehensive EmONC services package. It is
Himalayas and Hindu Kush. With serpentine roads and pertinent to mention here that GB has a maternal
in certain areas just rocky mountainous tracks being mortality rate of 600/100,000 live births (2).
their only means of commute from far flung towns and With the national incidence of poverty at 29.5%
villages to the main cities of Gilgit and Skardu. GB has an and a literacy rate of GB at 43%, it is veracious to reason
estimated population of 1.3 million and three that health, education, and economic stability are all
administrative divisions; Gilgit, Baltistan, and Diamer, densely intertwined issues which cannot be untangled
which are further ramified into ten districts. There are 5 independently (3,4). Nonetheless it is the responsibility
District Head Quarter Hospitals (DHQ), 27 Civil of the state to make quality healthcare accessible and
Hospitals (CH), 15 Basic Health Units (BHU), and 2 available to the masses.
Rural health Centers (RHC) in the region. (1). Another grave issue is that the doctor to population ratio
A public health facility assessment was in GB is alarmingly disproportionate i.e. 1:4100 whereas
conducted in all the DHQs, CHs, RHCs and 20% BHUs the national statistic is 1:1206 (5,6). This statistical

to determine the availability and quality of maternal, child evidence testifies to the stark reality that health care in
and newborn services by evaluating the following Gilgit-Baltistan is in an appalling state. There is no
parameters; infrastructure, training of staff, availability of trained medical specialist and neonatologist in Skardu
drugs and equipment, work coordination and city and no trained psychiatrist in public sector in the
supervision, service delivery protocols, management Gilgit Baltistan region. There is only one psychiatrist in
information systems, infection control and death Combined Military Hospital (CMH) Gilgit, who is

reviews. The report revealed that all BHUs assessed
were unable to provide 8/6 (8 hours a day, 6 days a
accommodating psychiatry patients from the entire GB
region.

Pakistan Journal of Public Health| Vol. 7, No. 2| June 2017 113

Amimah Fatima Asif Healthcare Challenges In Gilgit Baltistan

The Gilgit Baltistan Demographic and Health Pakistan include Pub Med, Google Scholar, and Google
Survey 2008 also shows noteworthy statistics, revealing Web search. The references include journal articles,
that women delivering in a health facility are only 39% government surveys, private sector and non-
and child mortality rate for both sexes is estimated at government organization (NGO) reports, information,
92/1000 live births. Furthermore, contrary to World and data from international development organizations
Health Organization (WHO) recommendations only a websites.
little more than one third (37%) of children are Problems in Healthcare Delivery
exclusively breast fed in GB, with high prevalence of There is a wide spectrum of issues in the heath sector in
micronutrient deficiencies such as Vitamin A deficiency GB, some of which are the ubiquitous lack of doctors,
in infants. The prevalence of all types of diarrhea among trained paramedical staff, laboratory technicians, state-
children under five years of age during the two-week of-the-art equipment for diagnostic, and treatment
survey preceding the study was found to be 22% (7). purposes. People who have the means to reach the
The prevalence of mental health disorders is relatively big cities, Gilgit and Skardu, for treatment are
also an unchecked realm of health care in Pakistan in seen swarming and choking the outpatient clinics and
general but particularly in GB. Pakistan is a developing emergency rooms, where specialist doctors are sparse
country, with GB largely constituting of a population with and the treatment options are limited. Patients then
orthodox views and limited horizons of thinking. Hence inevitably have to travel to major cities down south for
seeking help for psychiatric and psychological disorders better treatment options (12). As for the hefty population
particularly, is associated with a social dogma of bracket that is unable to access and afford tertiary care
conservatism, which makes people resist, or decline hospitals in Gilgit, Skardu and the south of the country,
help for mental illnesses. On the other hand in health are mostly residing in far flung towns and villages
care settings, psychiatric illnesses are commonly under bordering areas as rangy as K2 and Siachen. They are
diagnosed and under treated by health care providers. left to wait for divine intervention or to quietly succumb to
These hurdles are a few reasons as to why accurate suffering and decadence.
national indicators of psychiatric morbidity are scarcely The DHQs, THQs, BHUs, and dispensaries are
available and only a handful of studies are documented of negligible benefit to the community since doctors are
to have examined this facet. rarely available, a handful of laboratory investigations
A study conducted in district Ghizer shows age are being performed, there is a serious shortage of
specific suicide rate in females of 61.07/100,000 per trained laboratory and operation theater technicians and
year, which is the one of the highest in the world (8). trained nursing staff, and no basic medicines are
Another article published in Passu times has revealed procurable. Accident and Emergency departments are in
statistics that show substantial increment in suicide rates dismal state with limited availability of lifesaving drugs
throughout Pakistan, specifically in the Gilgit Baltistan (13).
region; 23 suicides were reported in Gilgit in 2012, with Hospital set ups lack standard operating
gender breakdown of 10 females and 13 males (9). A procedure for hospital laundry segregation, collection,
cross-sectional study conducted in Chitral and Khyber and disposal. Additionally hospital waste management
Pakhtunkhwa (KPK), which is a region ethnically and policy is almost nonexistent. Some hospitals also have
culturally similar to GB, uncovered that the suicide rate serious issues of water supply shortage, making patient
in females is almost double than that of men, of 168 care, hospital cleanliness and maintaining even basic
suicide cases studied, 68% were women and 38% are hygiene extremely difficult (14). Winter season is harsh,
men. The leading causes identified were family issues, with patients trickling into hospitals and other facilities
lack of confidence, mental health problems, and continuously nonetheless no well-regulated, round the
academic failures (10). clock heating system for pediatric and adult patients in
Depression is the most common mental health wards and for attendants in waiting areas is being
disorder, which has its origin in our society's social and provided.
cultural dogmas. A pilot study conducted to determine The silver lining in this crisis are the Lady Health
socioeconomic factors of depression in females of Visitors (LHV), Lady Health Workers (LHW), and Dai
district Ghizer, GB showed results that identified (Traditional Birth Assistant, TBA), they are the
domestic abuse (verbal and physical) and poor relation caretakers of maternal and child health at the grass route
with in laws as principal causes of depression. Non level. They offer door to door antenatal checkups and
cordial relations with in laws were found to be a strong assisted home deliveries. Despite of this there are many
predictor of depression in females (11). reported cases of complications during labor and
Methodology delivery such as obstructed labor and postpartum
This review article aims to analyze the healthcare crisis hemorrhage, due to the unskilled management of
in the Gilgit Baltistan region in an attempt to find practical patients by untrained health workers and TBAs.
solutions to improve the healthcare delivery system and
achieve health for all. The web links searched for Time and again donations by international non-
research statistics and data on the northern region of government organizations (NGOs), donor

114 Pakistan Journal of Public Health| Vol. 7, No. 2| June 2017

Amimah Fatima Asif Healthcare Challenges In Gilgit Baltistan

organizations, and public-private collaborative projects healthcare coverage plans, such as in the United States,
to health facilities have been made. With laboratory and have made state-of-the-art healthcare delivery the
equipment, examination apparatus, dental chairs, chief indicator of their burgeoning economy. On the other
examination couches and other hospital essentials hand we have chosen to ignore the alarming state of our
being donated (15). But the scrupulous use of all these healthcare sector and the suffering of the
donations is crucial otherwise they have been wasted in underprivileged among us. Health constitutes 0.9% of
the paste due to lack of use or improper use. Pakistan's gross domestic product (GDP), provincial and
Conclusion federal combined, making it one the smallest
Resonating with a lack of accountability and expenditure heads (18). This meager number is
professionalism, it is often claimed that there is a sheer unequivocally depicting the apathy and lack of
lack of funds responsible for the unfortunate condition of importance the government holds for healthcare. The
health facilities; it will not be incorrect to assume that state of government hospitals all over the country is
commensurate with the population load the funds dreadful, with the well-off relying mostly on private
available or allocated to the respective health hospitals; it seems that the poor are left to suffer in
departments are adequate, if utilized judiciously and silence and eventually wither into oblivion.
honestly.
On the other hand it is also pertinent to highlight References
the essential role of doctors in improving the healthcare 1. Pakistan Census Organization. Pakistan
situation in this hard area. Doctors are mostly very Population Census 1998. Statistics Division,
reluctant to go and serve in a far flung, hard area which is Federal Government of Pakistan. [cited January
difficult to access from the rest of the country and is 20th 2017] Available from:
lacking in very palatable facilities. These doctors should http://www.pbs.gov.pk/sites/default/files/other/p
conscientiously realize their responsibility and duty to ocket_book2006/2.pdf.
give back to the community that nurtured them (16). 2. Health Facility Assessment-Provincial Report
Although recently the government of Gilgit Baltistan has Gilgit Baltistan [cited January 20th 2017]
offered a pay incentive package to attract doctors but Available from: http://pspu.punjab.gov.pk/
despite of this effort, unfortunately the shortage of system/files/HFA-Gilgit.pdf.
doctors is persisting. To rectify this at a very nascent 3. Pakistan Overview- The World Bank [cited
level, it is necessary that medical education be January 20th 2017] Available from:
redesigned to substantially incorporate the facets of https://www.worldbank.org/en/country/pakistan/
primary and secondary health care and their overview.
unparalleled significance in improving the health 4. Education Statistics Gilgit Baltistan, Gilgit
indicators, thus defining the fundamental role of social Baltistan Social Welfare Organization [cited
physicians and public health specialists for medical January 22nd 2017] Available from:
students. Furthermore, medicine supply chain should be http://www.geogilgit.org/edu_stats.php.
very responsibly handled and maintained with the supply 5. Health Budget and Expenditure Analysis (2008-
and delivery of life saving drugs ensured to each health 2009 to 2010-2011), Health department Gilgit
care facility across GB. Baltistan. [cited January 22nd 2017] Available
In addition to this the LHVs, LHWs, dais and f r o m : h t t p : / / p s p u . p u n j a b . g o v. p k /
other paramedical staff need refresher trainings and system/files/Health%20Budget%20%2526%20
knowledge of latest guidelines regarding maternal, Expenditure%20Analysis%20GB.pdf.
neonatal and child health care to deliver health services 6. Economic Survey of Pakistan (2011-2012),
in a more professional manner and therefore reduce the Finance Division, Government of Pakistan [cited
chance of complications during labor and delivery in both January 22nd 2017] Available from:
mother and baby (17). http://www.finance.gov.pk/survey/chapter_12/1
Lastly an innovative health care model should be 1-HealthAndNutrition.pdf.
constructed and implemented where the infrastructure is 7. Gilgit Baltistan Health and Demographic Survey
revised, medical personnel is trained efficiently, health (2008), National Institute of Population Studies
care facilities are equipped to handle at least basic (NIPS), Government of Pakistan [cited January
medical emergencies. Surmounting all this should be 22nd 2017] Available from:
good governance and an astute administration, whose h t t p : / / w w w. n i p s . o r g . p k / a b s t r a c t s . p h p ?
pivotal role can't be emphasized enough in the smooth pageno=4.
execution, running and revamping of the current health 8. Khan, M. M., Ahmed, A., Khan, S. (2009).
program. Female suicide rates in Ghizer, Pakistan.
It is disheartening to see the common man being Suicide & Life-Threatening Behavior, 39(2), 227-
deprived of basic healthcare facilities, whereas 30.
advanced nations have championed affordable and 9. Baig, S (2016), Alarming rise of Suicide in
quality healthcare delivery by instituting universal- Pakistan [cited 4th February 2017] Available

Pakistan Journal of Public Health| Vol. 7, No. 2| June 2017 115

Amimah Fatima Asif Healthcare Challenges In Gilgit Baltistan

from: https://passutimes.net/News/1158.
10. Ahmed, Z., Nisa, Q., Yousafzai, AW., S, Khoja.,
J, Chaudhry. Trends and Patterns of suicide in
people of Chitral, Khyber Pakhtunkhwa,
Pakistan. Khyber Medical University Journal, Vol
8, No 2 (2016)
11. Bano, S., Fatima, A., Saadat, S et al.
Socioeconomic factors of depression in females
of District in Gilgit Baltistan- a pilot study. 8th
National Symposium on Depression: August
20th 2016, Rawalpindi, Pakistan.
12. Pakistan: Overcoming Barriers to Healthcare,
United Nations Office for the Coordination of
Humanitarian Affairs (UNOCHA) [cited February
4th 2017] Available from: www.unocha.org.
13. Health Facility Assessment-Gilgit Baltistan,
District Gilgit, Technical Resource Facility. [cited
February 2017] Available from:
http://pspu.punjab.gov.pk/system/files/HFA-
Gilgit.pdf.
14. City Profile: Gilgit, Urban Observatory Report
2011, United Nations-Habitat (UN-Habitat) [cited
February 4th 2017] Available from:
http://urban.unhabitat.org.pk/Portals/0/Portal_C
ontents/Gilgit%20Baltistan/Gilgit/FINAL%20RE
PORT.pdf.
15. Pakistan Donor Profile and Mapping Report by
United Nations [cited 4th February 2017]
Available from: http://www.un.org.pk/wp-
content/uploads/2014/04/Pakistan-Donor-
Profile-and-Mapping-by-UN.pdf. Published
2014.
16. Mir, AM., Shaikh, MS., Gul, R., Mankani, N. To
serve or to leave: a question faced by public
sector healthcare providers in Pakistan. Health
Research Policy and Systems 2015, 13(Suppl
1):58 DOI: 10.1186/s12961-015-0045-4
17. Zeenat, N, Jan, R. Midwifery in Gilgit Baltistan by
Aga Khan Health Service, Pakistan. Journal of
Asian Midwives. 2015; 2(1):42-45.
18. World Health Organization Global Health
Expenditure Database [cited February 7th 2017]
Available from: http://apps.who.int/
nha/database.

116 Pakistan Journal of Public Health| Vol. 7, No. 2| June 2017