Reforming Pakistan’s health sector

Reforming Pakistan's health sector

“Health is a human right, not a privilege to be purchased” – Shirley Chisholm

It was not long ago that the world realized that security encompassed more than just prevailing ideas about the exercise of power, within and between countries, and explored the concept of human security – acknowledging the mutual vulnerability and interdependence of people, and the need for global cooperation, collaborative efforts, and unified solutions to contemporary issues with humans at the center of the debate.

Healthcare came to be seen as the right of every human being, as opposed to a privilege that could be bought, or rationed based on the ability to pay. It was then that the provision of healthcare got divorced from a capitalist venture, and came to be seen as a right that the government had to ensure through programs and policies under the public healthcare system. Campaigns, electioneering and policy incorporated the promise of healthcare, and continues to garner support based on the guarantee of human health.

While the struggle to cement the foundation of the healthcare system is an ongoing effort even in the most developed countries, some adopt an ostrich approach to the crumbling and almost non-existent healthcare system that continues to deny citizens their basic right. A stroll through the corridors of the public hospitals in Pakistan paints a somber picture; one where misplaced priorities, corruption, stifled funds, and a rotting infrastructure glares at you and reveals the worth of human life in a country that has yet to breakaway from the rut of a traditional approach to security.

Glaring reality

Pakistan’s greatest struggle over the past has been to switch over from a security to a development-oriented welfare state. To provide health facilities to the citizens, there is a Universal Health Care system in Pakistan, which entails that any citizen can get treatment at public sector health care facilities in the country. According to a report by the Pakistan Economic Survey in 2014-2015, currently Pakistan has a network of healthcare infrastructure with “only 1,142 hospitals, 5,499 dispensaries, 5438 basic health units, 671 maternity and child health centers with only 175,223 doctors, 90, 276 nurses, and 118,041 hospital beds for a population of around 190 million”.

The overall negligence towards improving healthcare is translated into numbers, where between 1995-2014 an average of only 2.83 percent was spent on health as a percentage of GDP. The budget, is thus steered, as typically in security states, towards the provision of security in traditional terms – that too in vain.

To think that the meager cut is in reality spent on the resurrection of the healthcare system in Pakistan is a naïve thought in itself. Siphoning of funds, theft, and corruption is known to occur at various levels as far as money is concerned. Bureaucratic and political leakage of funds, fraud, and corrupt practices are embedded in the Pakistani reality as a consequence of a mismanaged expenditure system, organizational deficiencies, the absence of effective auditing and supervision, as well as poor fiscal controls over the flow of public funds.  Funds are more often than not misused and embezzled in the healthcare system, typically through an overstatement of the costs of essentials needed in hospitals, so much that the cost of basic scrubs needed by doctors and nurses is inflated to 5000 PKR per piece, where in reality it costs a fraction of the amount.

In a publication titled ‘Health Care Services and Government Spending in Pakistan’, Pakistan’s healthcare system is described as:

“inadequate, inefficient, and expensive; and comprises an under-funded and inefficient public sector along with a mixed, expensive and unregulated private sector. These poor conditions in the health sector may be attributed to a number of factors like poverty, malnutrition, unequal access to health facilities, inadequate allocation for health, and high population growth and infant mortality.”

Despite the glaring reality, the priorities of the government lie elsewhere – its disregard is revealed through the overcrowded hospitals due to a dearth in medical colleges and hence the availability of doctors, the sharing of hospital beds by patients, where in a recent case a woman was treated on the floor of a hospital in the provincial capital Lahore, and where people have to travel for hours on end to get treated – met by a doctor and their staff with a lax attitude, and an air of annoyance.

And that is the other side of the coin.

The lack of people skills on behalf of the doctors and their staff, too, are awarded to the crumbling infrastructure of the healthcare system as a consequence of the laxity of the government. In a recent case, an X-ray machine at the largest hospital of the province was out of order, and remained so for at least two weeks – nobody seemed to have noticed. Similarly, only one ECG machine was present, and patients had to wait their turn. According to an attendant:

“The nurses had asked me to learn inserting tube because the staff did not have time. It was a tedious job. Many times the staff would simply take away the machine to use on another patient”

This only points to the worst: hospitals are overcrowded, staff is underpaid, and doctors have to make do with whatever equipment they have in the little time they have, to see and treat a hoard of patients It makes for an ugly concoction, where there’s a higher risk of human error, accident, as well as coarse behavior in the case of an overworked staff that’s not compensated. In response to their protests, the government either makes promises to rectify the issue, or responds through teargas and a police force equipped with batons.

And the problem persists.

Potential change

In the efforts of the present government, Prime Minister Nawaz Sharif has launched a state-run health insurance programme as a “step towards making Pakistan a welfare state” – in his words. However, skeptics see this as a novel way of misusing government funds – the modus operandi will be tripartite, where the PML-N office holder, the insurance company, and the hospital could possibly cash bills without any genuine patient. If that is not to be believed, the habitual ignorance of the government towards ignoring the root of the problem, a crumbling infrastructure in this case, and piling on schemes after schemes is an even bigger problem. Health-insurance becomes a futile effort if machines are inoperable, there’s a lack of doctors, hospital, medical colleges, as well as equipment.

However, recently, Pakistan has agreed on a 5 Year National Action Plan for Health Security – the implementation process of which will begin in July 2017, with “key priorities and drivers identified for detailed costing, time lines, intra/inter-linkages, performance indicators for a phased implementation”. The plan is also set to address the issue of funding gaps, and to seek potential funding sources, including domestic funding, both public and private, and potential donor investments and requisite resource availability. One can only hope that unlike most policies in Pakistan, this one sees its conclusion and is implemented in its truest form.

The dismal condition of the public health infrastructure necessitates increased spending, and a larger chunk of the budget allocated in its direction, drafting and implementation of long term policies addressing the root of the problem, regulating the exorbitant private sector, as well as an increase in teaching hospitals and specialized centers in the often forgotten Balochistan, Sindh, KPK, Gilgit Baltistan, and South Punjab.

It should not be forgotten that a state that absolves itself of its responsibilities is paving way for its own downfall. Life is cheap in Pakistan, and that’s something that needs to change.

Spearhead Research