Who pays for health & education?

By Zubeida Mustafa
Source: Dawn

THE slide in the quality of social services in Pakistan has prompted some serious thinking in concerned circles on who should pay for the education and health care of the people. Now that the idealism of the left is no longer fashionable and market-mania (to borrow the Nobel Prize winning economist Amartya Sen’s term) has swept aside all rational considerations, it requires some courage to suggest that the state must be responsible for educating its citizens and attending to their basic health needs.

Many people in a position of authority in Pakistan now unabashedly declare that the government cannot undertake this burden since it does not have the resources to finance a welfare state. Even if we set aside humanitarian and religious considerations, simple economic compulsions should make us think otherwise. Amartya Sen, who links freedom and development together, describes education and health as ‘enabling factors’ since they promote freedom by offering more choices to the people and empowering them to resist oppression.

Hence a society which is truly concerned about its own economic development must feel concerned about the education and health of all its citizens. If it is accepted that economic development is not possible without a modicum of social development, then how can a state leave its citizens to fend for themselves in obtaining education and health care, especially when a very large number of them live below the poverty line? Logically, social sector spending should be viewed as an investment in economic progress.

These are not happy times to promote the concept of a social welfare state which is under attack even in the affluent West from the radical right and the capitalists. Many of the social democracies, such as Sweden, Britain, Canada and Germany, have scaled down the benefits which they liberally offered to their citizens at one time. In spite of the cuts, schooling continues to be free — hence also compulsory — in all the countries mentioned above. At the most, parents have to spend a relatively nominal amount on books and stationery for their children.

Hospital care is also provided free of charge to people needing it in these countries. Patients may be required to pay for their medicines as in Canada and Britain but there too the charges are waived for children and the elderly.

Those who have argued against the state providing social services in Pakistan have pointed out that the developed states of the West introduced their social security net only after they had reached a respectable level of economic development and could effect a redistribution of wealth without impeding economic growth. The champions of the marketplace in Pakistan have also pointed to the existence of a private sector in education and health in all these countries mentioned above.

But such comparisons are misleading, given the contrast in their conditions. The aid-giving agencies which have been insisting on the withdrawal of subsidies for various services are trapping us permanently in a bog of poverty and underdevelopment. Since the process of structural readjustment was undertaken, the country has been retrogressing in the social sector.

Poverty has been on the rise. The number of illiterates has increased and the standards of education in public sector institutions have fallen. The morbidity rate has also gone up, as a number of diseases have been visibly on the increase. In these circumstances when the ‘enabling factors’ are on the decline can economic growth ever take place?

It is a pity that the crunch has come at a time when many other factors have added up to create a crisis in the social sector. The high birth rate has left the country with a massive population of 150 million of whom 46 millions subsist on less than one dollar a day.

Apart from the population size, which is a testimony to the failure of our family planning programme, there are other factors which have cumulatively created the present crisis. They are the aging of the population, the increase in the incidence of many diseases, the change in people’s lifestyles, the state’s failure to attend to public hygiene and sanitation, environmental pollution and other ecological factors. All these have added to the burden of disease in the country.

The education sector has been affected by the population growth and the increasing demand for education brought about by the rise in public awareness about the advantages of a good education. The information and communication explosion has also created higher expectations among the people who had previously remained reconciled to their state of deprivation.

Thus, new demands have been created which are not being met. The government has responded to this situation by adopting a strategy which is directed towards: 1) recovering users’ charges from consumers in the health and education sectors; 2) promoting the public-private partnership approach in which the government has inducted the private sector in the health and education fields; 3) slowing down the expansion of primary education and basic health facilities in the public sector.

It is plain that this strategy has failed to produce positive results as the appalling state of the education and health sectors testifies. It has led to a marked decline in the services of public sector institutions while tilting the balance towards the private sector, which has made health care and education prohibitively expensive. More and more people who do not have the means are being forced to send their children to private schools and take their ailing relatives to private hospitals. When private sector institutions are allowed to operate on a laissez faire basis, they cannot be forced to reduce their charges.

The wiser approach would be to regulate the working of these institutions in such a way that they complement the social welfare role of the state. But before it proceeds to enlist the cooperation of the private sector, the government must put its own house in order. Official sources have revealed that the public sector often fails to utilize all the funds available for education and health. This is to be attributed to bad management, corruption, embezzlement and wastage. Given the exemplary services provided by some public sector institutions headed by devoted and motivated people, one feels that the situation is not beyond rectification.

The next step would be to mobilize additional funds. There are two sources which could be tapped. One, the government should cut down its defence spending — especially on its nuclear programme which is a white elephant for a country with people as uneducated and in such poor health as Pakistan — and divert these funds to the social sector. Two, resources can be raised from public donors and philanthropists as many institutions are already doing successfully.

It might appear paradoxical that a society notorious for tax evasion should donate so generously to charitable causes. But the fact is that institutions with a reputation for delivering — the Edhi Foundation, for instance — do mobilize voluntary donations without much difficulty. The key precondition is that the people should be convinced that their money is being put to good use and is not being swindled — as is the general impression about the taxes collected by the government.

Once the government has established its credibility, the private sector should be inducted into the programme to provide social protection to the people. This can be in the form of trust hospitals and schools which could be encouraged by the government and provided subsidies and grants to enable them to keep their charges low and affordable. But that should not mean that their standards should be poor.

True, they may not be able to match the high standards of private sector schools and hospitals. But they should at least provide reasonably good services. It may be pointed out that in Germany and Britain the ratio of children in state-funded and private schools is 99:01 and 93:07 respectively, when in Pakistan it is 85:15. Although it is widely admitted that private institutions have a higher standard state-funded schools and hospitals in Britain and Germany do fulfil the minimum needs of the people. Why can’t ours?