In case of illness and debt: right to health

Muhammad Boota, a domestic helper in Lahore, needs an insulin injection every ten days to control his diabetes. But just one of these injections costs about a third of his meager monthly salary.

As with millions of Pakistanis with health problems, the only thing keeping food on the table and a roof over his head is unreliable charity support to help pay for an unaffordable drug he cannot live without. His story is just one of many examples of Pakistan’s dire healthcare crisis and one of many reasons why the government must change course to ensure every Pakistani’s human right to the highest attainable standard of health.

According to Pakistani non-governmental health care organization Sehat Kahani, more than 50 percent of Pakistanis do not have access to basic health care, and about 42 percent do not have access to health care. But recent changes in government policy are likely to make this worse. In February, the government raised the prices of 146 essential medicines, putting many of them even further out of the reach of people on lower incomes.

A major reason for the dismal state of healthcare in Pakistan is the lack of government funding. According to 2021 figures, the Pakistani government spends the equivalent of just 0.84 percent of its GDP on healthcare – down from 0.94 percent in 2019 and less than a third of the average of other lower-middle-income countries (2 .62 percent). . Although public healthcare expenditure is not a sufficient condition to guarantee the right to health, adequate expenditure is a necessary condition.

In its recent report “Global Failures on Healthcare Funding,” Human Rights Watch analyzed two decades of global healthcare spending data from the World Health Organization (WHO), looking at global and national trends. The researchers focused on how much both governments and private households spend on healthcare, the impact of out-of-pocket spending on the right to health, and how countries can shift this balance to improve access to healthcare through increased financing.

Human Rights Watch’s analysis shows that most governments spent no more than 5.0 percent of their GDP or 15 percent of their national budget on healthcare in 2021, the most recent year for which data is available. These are two important and common metrics for assessing whether countries are on track to ensure universal health care, a goal distinct from but rooted in the human right to universally accessible health care, derived from the International Covenant on Economic, Social and Cultural Rights.

While the world lagged behind these key spending targets, Pakistan lagged even further behind. In 2021, out of 189 countries, Pakistan ranked 176th in the amount of money the government spent on healthcare, measured relative to the size of the economy, and 170th, measured relative to the size of the national budget. Simply put, the government has not made healthcare financing a priority.

Many countries that spent the most on healthcare that year were high-income countries. But many governments from less wealthy countries prioritized healthcare financing. Cuba, for example, reported spending the equivalent of 12.6 percent of its GDP on healthcare in 2021. Bolivia, a lower-middle-income country like Pakistan, met both spending criteria in 2021.

If governments do not finance healthcare, individuals and households must bear the burden. In 2021, over 57 percent of Pakistan’s healthcare expenditure was borne by patients and families through out-of-pocket costs such as Boota’s insulin bill. Reliance on out-of-pocket payments can increase healthcare inequalities, widening the gap in quality of life and life expectancy, rather than ensuring the availability, accessibility and quality of healthcare.

Pakistan’s current healthcare crisis comes within a broader context of rising poverty, inflation and unemployment, as the country faces one of the worst economic crises in its history. The situation threatens the human rights of millions of people, including their rights to health, food and housing.

But at least a quarter of Pakistan’s population lived below the national poverty line well before this crisis. The World Food Program estimates that in 2018, 21 percent of Pakistan’s population was malnourished and 44 percent of children under the age of five were stunted. The Asian Development Bank reported that for every thousand children born in Pakistan in 2020, 65 would die before their fifth birthday. Nearly 25 percent of the population had no access to electricity in 2020.

Pakistan is also among the countries most vulnerable to climate change. The country is facing warming rates significantly higher than the global average and will most likely be accompanied by more frequent and intense extreme climate events. These events are especially threatening for economically and socially marginalized populations, including the elderly, people with disabilities, and people living in poverty and in rural areas.

Pakistan’s government has entered the latest round of negotiations with the International Monetary Fund (IMF) on a three-year, multi-billion dollar program to avert an economic collapse. The acute shortage of foreign exchange last year left many imports, including essential medicines, in short supply or inaccessible.

Debt servicing is a major barrier to public investment in healthcare. Human Rights Watch found that Pakistan paid about seven times more per person to service its external public debts in 2021 than it paid to health care. The IMF and credit rating agencies estimate that interest payments on its debts will consume between 50 and 60 percent of the total government debt. government revenues this year – the worst ratio of any comparable economy in the world.

Creditor governments and institutions such as the IMF should assess the impact of debt payments on governments’ ability to meet their human rights obligations, including the right to health care, and consider debt restructuring or relief to ensure that countries like Pakistan can adequately protect their debts. rights.

But financing alone is not enough. The lack of investment in healthcare in Pakistan reflects a lack of political will on the part of authorities to tackle the problem. Pakistan has no constitutionally protected right to health care. The country’s constitution states that the state will provide “medical assistance” in the “Policy Principles” section, but these principles are unenforceable, aspirational goals. Even the “medical aid” objective is limited to citizens who cannot support themselves due to disability, illness or unemployment.

There is an urgent need for Pakistan to recognize the right to healthcare, in line with international standards. The country’s authorities must realize that upholding the right to health for the population is not optional.

The writer is a senior advisor for Asia at Human Rights Watch.