J Islamabad Med Dental Coll 2019 1 

Correspondence:  
Muhammad Ahmed Abdullah 

Email: drahmedabdullah83@gmail.com 

O p e n  A c c e s s   
 

 Structural Violence and Pakistan’s Health Situation 
 

Muhammad Ahmed Abdullah  

Assistant Professor, Community Medicine, Islamabad Medical and Dental College 

Structural violence was first defined by Johan Galtung as 

“A form of violence wherein some social structure or 

social institution may harm people by preventing them 

from meeting their basic needs”1 The concept has been 

studied extensively over the years and is considered as a 

major reason for strangled development in various 

resource limited settings around the world. The idea of 

structural violence implies that people in power fail to 

provide essential services for the people they are 

responsible for; this failure can be intentional or 

unintentional, nevertheless long-term effects influence the 

marginalized population adversely.2 
 

Pakistan is no stranger to structural violence; which is 

evident from the persistently deteriorating human 

development indicators of the country. Despite being the 

sixth most populous country in the world, a nuclear armed 

state, and a resource rich agricultural land, the health 

situation has gone from bad to worse. According to the 

Pakistan Demographic Health survey 2017-18, the 

neonatal mortality of the country is 42 per 1000 live births, 

the infant mortality rate is 62 per 1000 and the under 5 

mortality rate is 74 per 1000.3 Lack of effective health 

services, underutilized primary and secondary level 

healthcare delivery systems, an overburdened tertiary 

care system and a reactive rather than a proactive 

approach towards the health needs of the people are just 

some of the reasons for the dismal state of affairs. 

Pakistan’s political terrain has been uneven and fluctuant, 

yet no politico-social variations have been able to halt the 

constant deterioration in the health circumstances.4 

Pakistan is a triple disease burden country where 

infectious diseases, non-communicable diseases and 

accidents/violence all have their due share in the 

morbidity and mortality.5 One major point to consider here 

is the trivial proportion of our GDP spent on health. 

According to the Economic Survey of Pakistan for the 

financial year 2017-18, only 0.49% of the GDP was spent 

on health. This meager amount is no surprise because 

the highest ever percentage was 0.77% of the GDP in 

2015-16.6 These figures when viewed through the lens of 

human behaviors, are magnified in the form of the 

government’s intent for improving the health of the 

people. Most expenditure on health is out of pocket and is 

spent in the thriving private health care sector of the 

country. Mentioning the idea of the poverty disease cycle, 

at this point is also imperative, as diseases have dire 

consequences not only on the health but also the financial 

circumstances of people.7 
 

In the larger scheme of things, a health systems-based 

approach is the need of the hour, which has a proactive 

instead of a reactive outlook. In the current case scenario, 

the health system fails to solve problems that have been 

complicated by lack of awareness of the people and 

limited service delivery structure; this in turn further 

extrapolates the burden on the already crumbling health 

systems of the country. A robust leadership and 

governance model are probably the most needed rung in 

the ladder of health improvement and promotion in the 

country.8 

 

R e f e r e n c e s  

1. Galtung J, Höivik T. Structural and direct violence: A 

note on operationalization. JPR. 1971; 8(1):73-6 

2. Rotberg RI. The new nature of nation‐state failure. 

Washington quarterly. 2002;25(3):83-96 

3. National Institute of Population Studies, Pakistan. 

Pakistan Demographic Health Survey (PDHS) 2017-

18 

E D I T O R I A L  

mailto:drahmedabdullah83@gmail.com
mailto:drahmedabdullah83@gmail.com


 

                J Islamabad Med Dental Coll 2019 2 

4. Nizar H, Chagani P. Analysis of health care delivery 

system in Pakistan and Singapore. Int J Nurs Stud. 

2016; 8(2). 

5. Hyder AA, Morrow RH. Applying burden of disease 

methods in developing countries: a case study from 

Pakistan. Am J Public Health. 2000; 90(8):1235 

6. Ministry of Finance, Pakistan. Economic Survey of 

Pakistan 2017-18. 

7. Abdullah MA, Basharat Z, Lodhi O, Wazir MH, Khan 

HT, Sattar NY, Zahid A. A qualitative exploration of 

Pakistan’s street children, as a consequence of the 

poverty-disease cycle. Infectious diseases of poverty. 

2014; 3(1):11 

8. Shaikh BT. Health systems research in Pakistan: 

issues, challenges and way forward. J Ayub Med Coll 

Abbottabad. 2015; 27(2):257-8.