By Zubeida Mustafa
THE health sector in Pakistan is in a state of crisis. Yet the policy makers appear to be unconcerned about the sufferings of the people. The pity is that the induction of the so-called democratic government has not made the slightest difference to the quality of life of the common citizen.
Matters of more immediate concern to the common man than the constitutional and political conundrum have gone by default. Issues of governance and policymaking have been pushed into the background. How many politicians have cared to look into the implications of various policies which have been formulated by government functionaries without any parliamentary debate? How many have bothered to analyze the federal and provincial budgets, which have been presented recently, in a meaningful fashion? Have any of them attempted to monitor the implementation of various policies announced with such fanfare?
On the contrary, the energies and attention of the politicians and the media have been focused on the political tussle which has gripped the country since October.
All this suits the interests of the powers that be. Many of them are foreign donors who are acting in collusion with their local agents. It keeps public attention diverted from the basic issues which are understandably the real concern of the man in the street. One of these is the health care provided to the people and the health policy which provides the parameters for the health delivery system. .
In the last decade or two, the Pakistan government has been gradually disengaging itself from the social sectors under the directives of the World Bank/IMF combine. It has encouraged the private entrepreneurs to fill the vacuum thus created and has devised the concept of the public/private partnership in an attempt to make this shift in emphasis palatable.
One would not dispute the imperative of involving the private sector and the NGOs in the health delivery system of the country, given the financial constraints that exist. But the key factor in this arrangement is the role assigned to each of them. If the private sector assumes a preponderant role, it is inevitable that the cost of health care will rise and become increasingly inaccessible to the indigent, whose number has been escalating.
Some might argue that in absolute terms the government’s health budget has constantly been on the rise and it is unfair to accuse it of shirking its responsibility of providing basic medicare to the people. In the five-year period of 1995-2000, the government’s health budget went up from Rs 16.3 billion to Rs 24.2 billion — an increase of nearly 50 per cent.
But what needs to be assessed is whether this increase in the health budget has benefited the people in the same proportion. WHO’s World Health Report 2002 paints a depressing picture. According to this document, the health-adjusted life expectancy at birth in Pakistan is 50.9 years when our government places life expectancy at 63 years. In other words, if you adjust the years lost in illness, the healthy life span of an average Pakistani is considerably reduced.
This finding is further reinforced by the high incidence of disease in the country. This is not a very pleasing situation for people to find themselves in. While in comparative terms they may be living longer than their ancestors did, the state of their health is definitely more dismal than ever before. Even to sustain their unhealthy lives, people have to spend more and more out of their own incomes to obtain some relief from their suffering.
According to the WHO report, the private sector accounted for 75.2 per cent of the total amount spent in the health sector in the country in 1995. This share went up to 77.2 per cent in 2000. In other words, the private sector — this mainly means out of pocket expenses for most people — is spending nearly thrice the amount the government allocates to the health sector. This does seem to be quite a lopsided partnership.
And how does the government spend the money it earmarks annually for the health budget? A look at the budget documents presented by the federal and provincial governments last week shows that the bulk of the government’s health funds goes into the salaries of the staff.
In fact, this head also absorbs most of the increases whereas the spending on items such as medicines, X-rays, utilities (gas, electricity and water) has either remained pegged at the same level or has even been lowered. Hence the people have had to pay for this shortfall.
One could have accepted this imbalance with equanimity if the government’s public health policy had been directed towards creating a healthy and risk-free environment for the people. That would have resulted in a lower prevalence of illnesses and ensured a better health environment for the people. But this has not been done and one may well ask who should be bearing the cost of medical treatment of a person who suffers from infections caused by impure water, mosquito bites, insanitation and polluted air? If the government is failing in its duty to provide the people basic necessities such as potable water and ensure efficient disposal of sewage and garbage, it has no right to burden the people with the heavy cost of medical treatment of the diseases which are a result of these lapses.
Even in the field of preventive medicine, the failure is too palpable to be ignored. Recently a leading paediatrician pointed out that the immunization coverage in the country for the six preventable childhood diseases has declined.
According to him, it has fallen from 80-90 per cent in the eighties to 50-60 per cent today. With this poor performance, can we ever hope to eradicate diseases such as polio and tuberculosis which call for a concerted immunization drive?
From what the functionaries in the relevant departments have to say, it is plainly a shortage of funds and manpower that has hit the Expanded Programme for Immunization over the years. This is a pity because the EPI had got off to such a promising start two decades ago.
The shortage of funds is not the only problem affecting the public sector health institutions. A substantial amount of the money provided for health care is siphoned off by the corrupt among the staff. Sizable in number, that section freely indulges in corrupt practices. Pilferage by them from hospital pharmacies facilitates a regular flow of drugs into the open market.
In the absence of strict monitoring and the failure to enforce discipline, absenteeism is also on the rise — said to be as much as 30 per cent in some public hospitals and other health-care centres. The irony is that the private sector is relatively free from corruption and other irregular practices such as absenteeism, negligence, ineptitude and so forth.
But it is not inherently suited to undertake the responsibility of providing services at a low cost to the public. Moreover, it has never been known to enter the field of preventive medicine. where there is little scope for profit.
The only solution is for the government to enhance its own role and spending in this field. It is strange that in the Third World countries, where poverty is rampant and the people need greater state support, the governments are spending less and less on health care, thereby raising the financial burden of
individuals and families who have to pay considerably more in seeking the services of
private doctors, clinics and hospitals.
As against this in the industrialized states where the people are generally much better off, the governments provide greater social security and bear a substantial share of the burden of health- care spending. In Sweden, for instance, the government contributes nearly 75 per cent of the country’s health spending.
Even in the US, the bastion of capitalism and market economy, the government’s share in the health expenditure is nearly 50 per cent.
There is need to redefine the nature and scope of the public-private partnership in health and education in Pakistan. Given the poverty of the people and the virtual de-emphasis on public health and preventive medicine, it is the height of injustice to make people foot inflated medical bills presented by the private sector because they have nowhere else to go.