In the heart of Parachinar, a devastating humanitarian crisis is unfolding as over 100 children have tragically lost their lives due to a lack of medical facilities as a consequence of an extended blockade. This catastrophe is both a symbolic and a literal testament to decades of systemic neglect towards a broken healthcare infrastructure system in Pakistan. The crises pose a critical question: why does such preventable suffering persist in a country that aspires to fulfil the dreams of its founding fathers? The answer lies quite explicitly in the deficiencies of a healthcare model where the absence of decisive leadership and structural reform at the top continuously fails to address the needs at the grassroots2.
The blockade and the subsequent medical crises serve as a harrowing analogy to a deeply ingrained system of sacrifice. A system that thrives on the suffering of vulnerable groups to sustain an illusion of control and calm. Anthropologists report an archaic tradition from Maya antiquity with similar traits, one that symbolized elitist apologism3. A form of sacrifice embedded in a ritualistic and eschatological system that, in the eyes of the elite, justified the murder of the very people it claimed to protect. The practice, which went by the name of “kick”, or human sacrifice, was periodically done, particularly during times of crisis, such as impending disasters or existing calamities, to restore the cosmic balance. This duality of claiming to be benevolent while perpetuating violence resonates resoundingly and with a startling familiarity with modern-day healthcare in Pakistan5. Much like the Maya, we see the systemic negligence in Parachinar as a reflection of this “sacrificial logic” where the needs of the marginalized are ignored, and their suffering becomes a grimly forced reality of a system that does not work for them6.
Jungian psychology suggests that such archetypes are deeply embedded in the collective unconscious7. They are transgenerational and manifest in new forms suited to the 21st century. How so? The sacrificial logic of “k’i’ik,” where the ends justify the means, continues today. The frameworks in which the destruction of the few is rationalized as integral to the preservation of all society are still disguised within the ideological system upon which the Pakistani healthcare system operates.
In our hour of independence (circa 1947), the nascent republic inherited a rudimentary healthcare structure, which was predominantly centred on caring for urban populations and ill-equipped to address the issues faced by the large rural populace8. The justification for such disparate development is given as proper healthcare to the people living in cities as necessary for the young nation’s development, eschewing the needs of millions of rural people. In the 1970s, Prime Minister Zulfiqar Ali Bhutto sought to address this gap by establishing Basic Health Units (BHUs) and Rural Health Centers (RHCs). Still, chronic underfunding limited the impact of these programs. The 2000s saw a wave of privatisation where patients were shifted to a “fee-for-service” model, effectively excluding those unable to afford care9. Decentralization through the 18th Amendment further entrenched these disparities as provinces with limited budgets failed to meet healthcare demands10. Systemic inequalities and profit-driven models continue to dominate this public good, perpetuating elitist frameworks.
This elitism manifests in narratives where the poor are blamed for their healthcare challenges, echoing the Jungian archetypes of sacrificial logos. Just as the Maya elite justified the kick by attributing cosmic imbalances to the failings of the marginalized, modern elites justify systemic neglect by framing poor health on the poor’s behaviour. Factors such as a lack of education, poor hygiene, or failure to seek care are all cited whenever discussion arises on increasing funding towards healthcare or improving policies. For instance, in Tharparkar, where child malnutrition and maternal deaths are alarmingly high, narratives are often framed around the local population’s “unwillingness to modernize” or “superstitious reliance on traditional healers”. This deflection is glaringly apparent and grossly misrepresents the real issue and better policy-making and governance.
Here, we arrive at the central thesis of this article: the need for change to come from the top. To evaluate the potential success of this strategy, it is essential to look at analogous scenarios in the Pakistani context, where top-down strategies have successfully transformed structures for the better.
One of the most successful top-down reforms in Pakistan’s history was the Green Revolution in the 1960s. Spearheaded by the then President, Ayub Khan, the government introduced several high-yielding varieties of crops, modernized our irrigation system and provided extensive agricultural subsidies to farmers. This initiative revolutionised our agrarian sector, significantly reduced food scarcity, and stimulated economic growth in low-income regions. Another notable example, the National Immunization Program (NIP), has been hailed as Pakistan’s most successful public health initiative. Started by the Federal Government, this program combatted preventable diseases by widespread vaccination campaigns nationwide. According to data from the World Health Organization (WHO), the incidence of polio dropped by over 99% from 1988 to 2019. Similarly, the introduction of the Measles Catch-up Campaigns reduced measles mortality by more than 90% since their inception, with UNICEF reporting a notable decline in cases nationwide. History repeatedly shows us that by improving structures at the top, such as lawmaking, governance, and ministerial bureaucracy, the overall effectiveness and scope of public health initiatives did improve and will improve in the future regarding positive outcomes for the poorest.
Several key proposals can be considered to improve the impact of such programs. First, the Pakistan Medical and Dental council (PMDC) Ordinance requires extensive updates to align with contemporary practices and ethical standards. For instance, updates are needed in areas like orthopaedics, where surgical techniques, diagnostic methods, and post-operative protocols have significantly advanced yet remain poorly represented in the curriculum. Furthermore, the PMDC should adopt stricter protocols for clinical training, ensuring that students are exposed to modern techniques and surgical procedures. Outdated curricula and surgical stagnation are prevalent, creating a gap between medical education and the evolving demands of healthcare. I experienced the consequences of this during my struggle with a degenerative condyle condition. Despite visiting several specialists in Pakistan, I found no real solutions or treatments, partly due to the doctors’ limited knowledge and outdated practices, which I now realize stemmed from a lack of comprehensive medical education. This deficiency ultimately means that patients with complex conditions like mine may receive incorrect or insufficient treatment. Updating the PMDC ordinance will ensure that medical professionals align their treatment methodology with global standards, are aware of breakthrough advancements and can improve patient care.
Another critical area for improvement is the current bureaucratic hierarchy. Delays and miscommunication plague our healthcare departments, which must be addressed urgently. A detailed reform would streamline these departments by introducing clear role definitions and performance-based evaluation. For instance, key positions such as the Director of General Health Services and Secretary of Health should undergo merit-based selection, with laid out prerequisites such as having an educational degree in healthcare or public health policy and evaluating past contributions to healthcare outcomes. Clear lines of communication between federal health departments and provincial departments are also essential, especially when dealing with national health crises, such as the COVID-19 pandemic. One proposal is to empower the Health Services Academy to act as an intermediary between different departments, allowing quicker and more seamless decision-making and execution. Such an approach would help break down bureaucratic barriers and allow for faster implementation of health policies.
Additionally, the Drug Regulatory Authority of Pakistan (DRAP) Act needs strengthening to ensure better oversight of pharmaceutical products. A closer look at current frameworks reveals that, unlike more developed nations like the United States, Pakistan lacks an independent regulatory body like the FDA (Food and Drug Administration), which comparatively does not just monitor the safety of drug compounds but also oversees clinical trials. Establishing a body akin to the FDA would ensure more comprehensive regulatory controls on the approval, marketing, and post-market surveillance of pharmaceutical products, which are barely considered by governmental bodies. In particular, improving the standards for clinical trials and ensuring that they follow international ethical guidelines would foster greater public trust in domestic and foreign pharmaceutical products. This would be especially beneficial in eradicating taboos and local myths around taking medication, as well as reducing the proliferation of counterfeit medicines in Pakistan.
I initiated a political advocacy program in self-started efforts to address these systemic issues. The Public Health Parliamentary Caucus (PHPC), which garnered support from a diverse group of parliamentarians, has played a pivotal role in nurturing collaboration and improving lawmaking in Pakistan. It provides a valuable tool similar to other democracies: a bipartisan caucus dedicated to advancing public health. More tools like these are needed for the people of Pakistan to bear the fruits of democracy. Individuals and communities must unite to create political groups and platforms that focus on public health. At the provincial level, for instance, political groups could advocate for better resource allocation and develop solutions tailored to the province’s uniqueness. District-level platforms may target specific healthcare needs such as maternal and child health, vaccination drives or regional diseases.
Additionally, grassroots platforms can be built around specific health issues, where citizens, healthcare professionals, and activists come together to demand accountability from the government from the top. For instance, the Public Health Advocates (PHA) is a group of citizens that work on advancing public health in the United States by community-driven advocacy. In 2008, when the tobacco industry attempted to overturn the California Smoke-Free Workplace Act through a ballot initiative, PHA helped secure the defence of the law through their network of affiliated lawmakers and raised public awareness about the dangers of second-hand smoking.
Pakistanis can achieve similar, if not more significant,t victories if they gain the necessary political consciousness and collective will. However, this shift cannot be brought about through utilitarian lines of self-interested thought. It must be rooted in a genuine sense of service and compassion, where the well-being of others is prioritized above and before personal gain. Only by embodying the spirit of “khadi”, Iqbal’s call to selflessness and the elevation of good, can we pave the way for a more muscular, more democratic and more equitable healthcare system.
