Unsafe safety net

The entire healthcare system is on the verge of collapse due to political and bureaucratic indifference

Unsafe safety net

In previous articles, I have mentioned that even in a country like Pakistan healthcare is an emerging political issue. If we look back at the rise of a political ‘left’ in Pakistan the emphasis was initially on basic human needs like food, clothing and shelter (roti, kapraa, aur makaan).

Interestingly, at the time that the Pakistan People’s Party (PPP) came into being almost 50 years ago, both education and healthcare had become well-established as important parts of what is called the safety net. United Kingdom had two decades earlier instituted universal healthcare through the National Health Scheme (NHS) and free basic education (up to high school) was already being provided in most western countries including the United States. And yet, neither universal healthcare nor basic education was a major part of the PPP’s election campaign in 1970.

In the present day world, including countries like Pakistan, the political role of education as well as healthcare have become much more established than they were even a few decades ago. The importance of education in a rapidly advancing technological work environment is self-evident. And as education provides information and medical advances increase life expectancies, healthcare also assumes an increasingly important part of the safety net. Under the present government, healthcare for the poor is devolving into two parts. A ‘for profit’ private sector and a public sector that is largely based on charity care.

Here I want to make a few observations about charity care. First, Pakistanis as a people are very generous and are willing to support many charitable causes. In my own experience during my work in Mayo Hospital in Lahore a few years back, all in-patients in the hospital received free food three times a day paid for by business houses and other charitable organisations. The food was of good quality and was served in a very organised manner. Evidently the same was going on in all major government hospitals in the city. Also when I needed to help improve the physical plant of my department, I was able to raise significant amount of funds from private donors.

It is time to put to rest once and for all this nonsense about doctors being messiahs. From an historical perspective, messiahs all have had a rather bad and often sad end.

The problem that I found difficult to take care of was that of ‘zakat’ (religious poor tax). As all of us that have bank accounts know that a percentage from our accounts is deducted each year for zakat. However, zakat funds cannot be used for non-Muslims and for the ‘ashraf’ (superior lineage Muslims). Since I refused to either have means testing or religious examination of my ‘ward’ patients therefore I generally refused payments from the zakat funds. Even so we were able to perform close to three hundred completely free (but for a twenty rupee admission fee) open heart operations each year, I was able to do that using the officially allocated budget.

The reason why I bring up my experience with free open heart surgery at Mayo Hospital in Lahore during my period as the chief consultant is to emphasise a particular point. Much can be done with limited financial resources if there exists a will to do so. The ‘will’ is not just on the part of the physicians but also hospital administrations as well as their bureaucratic and political masters. The most important factor besides the determination to provide heavily subsidised care is that with the large number of hospitals and clinics run by the government, economy of scale comes into play.

Heavily subsidised medical care for all those people that might need it is also constrained by one simple problem. Remuneration for the medical staff. I have mentioned it before but let me repeat it. When I took over as a ‘grade twenty’ professor and head of the department in 2004 on contract, my monthly base pay was less than the cost of petrol I spent in a month travelling from my home to the hospital. And the monthly house allowance was a sad joke. It would be interesting to compare what I received with the remunerations, daily allowances, cars, houses, servants, drivers, and other amenities provided to a bureaucrat at the same level. Here of course the bureaucrats are the first to shout themselves hoarse that doctors are messiahs and so should live and work like messiahs.

It is time to put to rest once and for all this nonsense about doctors being messiahs. From an historical perspective, messiahs all have had a rather bad and often sad end. For all those in the bureaucracy and the press that talk of doctors as messiahs, I would want them to give me one example of a messiah that was ever able to earn a decent livelihood and provide a good life for his family. Let me just say that it is the bureaucrats that should act and live like messiahs and if they did, Pakistan would overnight become a corruption free country.

So enough of the mini rant and back to question at hand. Free universal healthcare must be the part of any manifesto presented by any major political party that has any ‘populist’ or ‘leftist’ pretentions. As far as ‘charity’ is concerned it is all well and good but charity goes counter to the dignity of human beings in a modern society. A state and a government should be able to provide basic amenities for its citizens. And neo-conservative, market based solutions are a cop out especially in a country where a significant percentage of the population lives at or below the poverty line.

Much soul searching is going on by the PPP about its future. Many well-wishers are offering advice about what the party needs to do to regain the support it had in the past. The PPP was a party of the left and it will only be successful if it can once again become a party that represents the dispossessed and the unfortunate along with those that want to make life tolerable for those that live on the edge of poverty.

As a practicing physician, I have seen many ‘white collar’ workers pushed into poverty by the cost of catastrophic medical care. And for many that subsist on a few dollars a day even the cost of basic and relatively ‘inexpensive’ medicine forces a choice between food on the table or a couple of blood pressure pills once a day.

Fortunately, there exists in most of Pakistan and especially in the Punjab, a province wide network of healthcare facilities stretching from the Basic Health Unit all the way up to the tertiary care teaching hospitals. Clearly the entire system is on the verge of collapse due to political and bureaucratic indifference. What is needed is that all major political parties should, in preparation for the next general elections, develop a detailed plan about how the existing healthcare system can be improved and expanded to provide universal healthcare that is affordable and adequate.

The Pakistan Muslim League-Nawaz ruling the Punjab for the last eight years has made its intentions quite clear. Privatise whatever can be privatised, build fancy medical centres and pay lip service to the ‘masses’ and their needs. Let us see what the other parties can offer.

Unsafe safety net