Health care The haves and the have-nots











By Zubeida Mustafa

A visit to a government hospital in Karachi can be quite a sobering experience. The overcrowding, the dirt, the air of despondency and the staff’s nonchalance towards the ailing hit you in the eye. In contrast, there are the private health institutions which exude affluence and professionalism and have an abundance of manpower to attend to the patients.

The key factor which makes all the difference between the two is finance. Money power can, after all, buy the best talent and help devise and operate the most efficient system. But the dilemma is that the latter works exclusively for those who can pay for it. Hence the big question being posed by health planners today the world over is: “Who should pay for medicare?” The message being conveyed — at least to Third World countries — is that when governments are required to pay from the taxpayers’ money for running the health care system, medical institutions are starved of funds and that affects their performance. Health, like any other consumer item, must therefore be purchased by the user at market prices.

According to the World Bank’s Development Report 1993 titled Investing in health, the government should not be burdened with the expenses of providing comprehensive health cover to the entire population. Broadly speaking, the World Bank suggests that the governments should concentrate more on fostering an environment that enables households to improve the health of their members, while channeling official health spending on a package of essential clinical services, envisaging pregnancy related care, family planning services, TB and sexually transmitted disease control and care for the common serious illnesses of children. For other medical services, the Bank considers it best to promote ‘diversity and competition’.81-19-11-1993b

On reading the finer print, one finds the anomalies too striking. On the one hand, who would argue with the Bank’s suggested strategy of poverty alleviation, promoting education and raising the status of women to improve the health of the people? It is now universally recognised that these are key determinants in the incidence of disease and the physical/ mental well-being of populations.

But on the other hand, the Bank intriguingly does not consider it necessary to categorically suggest an enhancement in the official expenditure on health. What it wants is a redistribution of the existing allocations (most niggardly by any standard) to make them cost-effective. By slashing their expenditures on tertiary health facilities, it is suggested, governments can release scarce resources for the prescribed package of public health interventions.

Public sector hospitals would be left with the job of providing treatment for minor infections, trauma, alleviation of. pain and medical advice to the poor. As for the health outlays on ‘discretionary, less cost effective interventions’, these will be assigned to the private sector. In other words they will be only for the rich who can pay for them while rhe governments’ limited health budgets will provide coverage of a rudimentary nature to the 81-19-11-1993apoor.

How would this strategy work in Pakistan? No one would deny that this country’s approach to public health has failed to produce the desired results the basic health related statistics for Pakistan are dismal and the World Bank report gives ample testimony life expec- tancy at birth was 56 years in 1990 while the median age at death was seven years (which indicates a very high infant mortality rate of 97 per 1000 births). The prevalence of malnutrition in children under five was 57 per cent.

Not surprisingly, the picture of the health infrastructure in Pakistan also emerges as being far from satisfactory. One doctor serves 2940 people and there is one nurse for 6,600 people and 0.6 hospital beds per 1,000 people. Only 25 per cent of the births are attended by medical personnel.

But what one needs to ask is whether it would improve the situation if the already meagre health budget of the government is shifted away from the existing institutions anp! the private sector is inducted “further into the health sector to promote “diversity and competition”.

Dr Haroon Ahmad, who has been involved in the PMA’s policy planning exercises, believes that this will not cure the ills of Pakistan’s ailing health sector. First of all, he emphasises, the slogan of privatisation is a fraud. Since by its very nature the private sector opts for projects which are profitable, this will amount to more and more resources being directed towards curative medicine. Hence, paradoxically, privatisation will amount to deemphasising preventive medicine. Can one imagine the private sector taking up vector control or mass immunisation programmes? At the same time there is no way to ensure that the local governments will step up their contribution to preventive medicine.

Dr Haroon also strongly opposes the strategy of downgrading the tertiary facilities in the public sector to generate funds for community projects. For that he staunchly advocates the enhancement of the national health budget to at least five per cent of GNP. On this there should be no compromise. As it is, Pakistan is spending an abysmally low amount on health. The health budget is barely 0.7 per cent of the GNP. According to the World Bank Pakistan’s per capita health expenditure in 1990 worked out to 12 dollars. It was one of the lowest in the world, the Third World average being 41 dollars. (India spent 21 dollars on the health of each citizen).

After the enhancement, even if the hospitals are given only a fifth of the health budget it would more than double their present resources. The remaining four per cent of GNP which would be set aside for primary health care and preventive medicine would be a massive sum, compared to the peanuts this subsector at.present receives. But without a feasible policy framework, it would be futile to attempt an effective and efficient redistribution of resources. That can be done only when the goals have been clearly spelt out and the strategy defined in a health policy, which is followed by the establishment of a monitoring machinery to ensure honest implementation.

The fact is that the privatisation of the health sector, especially on an ad hoc basis, will impoverish it even further and intensify the inequities in society. It is a myth perpetuated by those calling for an axing of funds to government hospitals that subsidies to them benefit the affluent classes who can afford to pay for the services they use. The state of the public sector hospitals should clearly convince the skeptic that only the indigent visit them. Would it be fair to deny them the few facilities that are accessible to them?

As for the belief that privatisation will promote greater efficiency and equity, nothing could be further from the truth. One has to compare the ratio of the private investment and government spending on health in different countries and their performance to assess the validity of the World Bank’s thesis. Take the example of the United States and Canada. In the former more than 55 per cent of the health expenditure is in the private sector while in Canada the government spends more than 75 per cent of the health budget. According to the World Bank’s logic, the US should be a paradigm of efficiency compared to Canada. On the contrary, America’s number one problem today is the inadequate functioning of its health sector. It is expensive, wasteful and leaves 40 million Americans outside the pale. Canada’s performance appears to be far more impressive than its neighbour’s as its health-related statistics testify.

The real test of the efficiency of a health delivery system is the optimum good it does to the optimum number of people. This is at once reflected in the health related statistics for that country. Simply providing the most modern and sophisticated medical technology and clinical services to a small elite class which can afford to pay for them should not be the goal of a health delivery system.

In Pakistan, already the private sector has emerged as the major investor in health. The Burhanuddin Commission noted in 1984 that 71 per cent of the national health spending came from private sources. According to the World Bank the government’s spending accounted for 53 per cent of the country’s health expenditure in 1990. Why is it that the private sector’s massive financial share has failed to produce results and half the population still has no access to health care?

According to the administration of the Civil Hospital Karachi, the cost of providing care to one patient works out to an average of Rs 5000. But less than Rs 50 is recovered from the patient by way of user charges which were imposed in 1985. As a result the standard of services is poor and the patient is forced to spend outside the hospital on medicines and other supportive services. But it would be a futile exercise to attempt to reduce this gap. True the user’s charges are nominal today but enhancing them to match the actual cost would be criminal. The disadvantaged classes who queue up in our government hospitals in quest of some relief from their agony can hardly afford to spend Rs 5000 on themselves for combating one bout of illness requiring hospitalisation.

Pakistan’s health sector, specially the private component, is badly distorted because of the massive presence of quacks and those claiming to practise alternative systems of medicine such as homoeopathy and tibh. There are estimated to be about 50,000 quacks — as many as there are doctors — in the country today. They provide service to a larger number of patients. The organised sector and the government have failed to eliminate the quacks or regulate the homoeopaths and hakims. The key to their success lies in their accessibility, availability and affordability. Even though their .treatment can be positively harmful at times, they flourish because there is no other option available. Besides they are reassuring and that makes all the difference to gullible and ignorant people who are in search of relief from pain.

It is time to dig out some of the old reports of commissions set up years ago to reform the health sector. These reports lie buried under dust on some bureaucratic shelf. They may still be relevant and could offer a feasible solution to the problems of the health sector. Since the recommendations they contain have never been published or implemented, they cannot be dismissed as being obsolete. The proof of the pudding is in the eating.  

Source: Dawn 19 November 1993