According to World Bank, in 1960, the GDP per capita a.k.a. income per person of Pakistan was more than double the amount of China’s. Fast forward to 2015: Pakistan has improved its GDP per capita 4X. In the meantime, China has improved it 25X.
Historically speaking, China’s meteoric rise to power and influence is an outflux of 60 years of reforms. In 1949, after gaining power, Mao Tse-tung tried to directly improve the Chinese economy, but eventually realized that the masses were plagued with more basal challenges. For example, in 1960 the average life expectancy of a person in China was 30 years – in contrast, the average life expectancy of a Pakistani in the same year was 47. The biggest killer – lack of hygiene awareness – would multiply epidemics exponentially, making the population density work against China. With 80% of the population living in rural areas and a minuscule supply of quality healthcare professionals, the situation seemed grim.
Mao tackled the problem by shifting emphasis from economic factors to social factors, institutionalizing long overdue healthcare initiatives in 1960. Being the most populous country, China needed scale built into its healthcare strategy.
Mao’s first initiative – called ‘Barefoot Doctors’ – took a widely adaptable boots on the ground approach of training farmers with basic medical and paramedical knowledge. In the role of a healthcare professional, their duty was to educate people about hygiene and provide first-touch non-emergency healthcare. The results amounted to more than doubling the life expectancy over the next 4 decades. Mao Tse-tung brought health to China, but didn’t live to see its aftermath. After Mao, Deng Xiaoping came into power and brought money to China. His focus on economic policy brought the country into the mainstream – that’s the China the world eventually came to know of. In retrospect, this history tells us that China’s greatest achievement was taking a bet that social factors needed to improve before the economic factors can register progress. This healthcare revolution has played an integral role in turning China into the defining economic miracle of our times.
Is there a lesson here for Pakistan?
Currently, 63% of Pakistani population lives in rural areas, where access to quality medical services is non-existent. There is a huge vacuum that is partially filled with quacks, dabblers, witch-doctors and alternative medicine practitioners. Moreover, the tiny sliver of a healthcare system that does exist is beset with structural fragmentation, gender insensitivity, inefficiency, and incompetency. Pakistan is one of the only two countries still struggling to eradicate polio, and one of the major reasons for this is a lack of awareness of the disease. Diseases like schizophrenia, and autism are considered unmanageable. Sexual, and reproductive health issues are not even acknowledged.
The country itself is faced with a precarious economic situation; burdened by heavy external debt, faltering productivity and rampant poverty. Unsurprisingly, Pakistan is currently in the lowest part of the bottom quartile on healthcare spending per person. Additionally, for every Rs. 100 that the Government spends, more that Rs. 40 goes towards servicing the interest payments on our national debts (i.e. not paying them off.)
At its peak, Barefoot doctors covered 90% of China and it took 22 years to get there. A localized Barefoot Doctors replica for Pakistan is an excessive approach that would require billions of dollars to setup, and 3 million people to cover 70% of Pakistanis. Add corruption, and inefficiency to the mix and we might see some results after a few decades.
Technology is the most efficient, and the ultimate enabler of scale with social media applications removing topographical, and several communicational barriers presented to healthcare professionals, something that was unavailable even to the very successful doctors on foot.
Donor agencies (e.g. DFID, USAID etc.) and governments are the primary enablers of the healthcare ecosystem; they are working with local partners to rid the country of specific healthcare problems. Their pockets: huge, their method: orthodoxical, their impact: fuzzy. Local enablers need to take a note from Innovation capitals (Silicon Valley, Zhongguancun, Bangalore, Seoul, Tel Aviv etc.) around the world, and tilt their focus toward innovation capital instead of operational efficiency.
And some are taking note of this progress; a Pakistani startup recently ran a small pilot to connect a portion of their user base from rural areas to doctors in urban cities. The idea was that the users will get reliable medical advice, with the caveat that the doctor would only advise on non-emergency issues. What they found during this test was shocking: couples mistake simple antibiotic treatable infections as permanent impotency; a teeming majority in certain areas of Pakistan use cow dung to disinfect their newborns. The potential for improvement is limitless here.
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Keeping in mind these issues in Pakistan’s healthcare, the ideal solution will need the ability to scale to remote areas. It will be hyper-localized in understanding the cultural nuances and subtleties. It will have a high return on investment (ROI) to survive the initial years of exploration, testing and re-iteration. It will be made by people who have the technical expertise and the gravitas to conceive and create such a product. It will need to digitally mimic China’s ‘Barefoot Doctors’. Since contemporary times are much more technologically advanced than Mao’s China, we can employ innovation to improve the results by leaps and bound.
The quality of a nation’s past, present and future is correlated to the quality of its human resource. The Chinese example provides undeniable evidence of this. Without adequate healthcare, Pakistan’s teeming millions will remain but a burden on the public exchequer and society at large. However, as improved healthcare seeds higher productivity, the same teeming millions will become our advantage, helping us close the gap with regional competition, and one day beating it.
Fahad Rao tweets @fahadrao