Globalisation of healthcare in Pakistan

Privatisation of services is a central and perhaps the most appealing characteristic of globalisation. Like many sectors, healthcare too is caught up with this trend, resulting in some unsavoury experiences especially in countries where regulatory oversights have been weak and often henpecked to the powers that be. Though most development policies advocate maximum government involvement in the provision of healthcare, governments in developing countries usually choose to abdicate this responsibility to the detriment of falling healthcare standards. Pakistan, too, has put on this mask of convenience in the name of globalisation.

Inadequate provision of healthcare services has been a sour truth that Pakistanis have had to face for decades now. Low spending, unfocused regulatory oversight and unequal distribution of healthcare facilities built a system that encouraged private practices, made quackery rampant and created a trust deficit between healthcare service providers and the recipients of their services. In due course, funds apportioned for healthcare were siphoned off to fund high-ticket projects. Such a blatant priority shift led to a high death toll and persistent suffering, even from avoidable and treatable diseases.

This was just the beginning of a new low in compassion and a divergence from the oath of doing no harm.

Being alive is sacred, for unless we breathe we cannot play our part on the so-called Shakespearean stage — the world. Breathing alone is not enough, though. It is one part of the complex phenomenon called health. People are alive on wheelchairs. They are alive in in a comatose state. They are alive with the assistance of life-saving machines and multiple medicines. Being alive is different from being healthy, which comes with a cost. That is why health forms part of a state’s governance structure informed by international and domestic policies, laws and legal obligations.

The Universal Declaration of Human Rights acknowledges the right of every person to a living standard that ensures health and well-being. Two multilateral treaties, the International Covenant on Civil and Political Rights and the International Covenant on Economic, Social and Cultural Rights (ICESCR) force countries that are either their signatories or have ratified them to provide their citizens a “right to enjoy the highest attainable standard of physical and mental health”. Article 12 of the ICESCR is based on the provision of child and birth care, disease prevention and conditions that allow access to medicine. The Cairo Declaration on Human Rights, born from the womb of the Organisation of Islamic Cooperation, also guarantees, in Article 17, a right to medical care and imposes on the state the obligation to provide it. The Constitution of Pakistan also gives the framework for the provision of healthcare in Article 38. It is obligatory for the state to provide for the wellbeing of its citizens through the provision of housing, clothing, education and medical relief. And then there is Sustainable Development Goals (SDG) to ensure universal health coverage for all segments of the population.

Notwithstanding the obligations and legal bindings, Pakistan has been spending a paltry amount, less than 1% of its GDP, on health, and has largely left the sector on private entities or international groups. What makes this arrangement precarious is the absence of regulation, oversight or collaboration. Some of the more well-known organisations active in Pakistan include Doctors Without Borders, USAID, the International Committee of the Red Cross and Direct Relief. Moreover, a number of organisations are providing specialised care in areas such as family planning and immunisation of children.

Pakistan has also demonstrated a weak commitment and a narrow capacity to provide healthcare facilities to its people in the form of disaster relief. In the event of major disasters, government response has been slow and unsatisfactory, again necessitating the intervention of international relief efforts.

The negative effects of low financing in the health sector are also visible in the rural-urban divide. While money is allotted for health services in major cities of Pakistan, people in rural areas are generally left on the mercy of the private sector, most of it populated with quacks.

The private health sector is highly entrepreneurial with its tentacles firmly entrenched. Almost 70% of Pakistan’s population go to private health service providers for routine consultation. What is alarming is the high percentage of private visits made for primary healthcare services, which is essentially considered the government’s domain.

The issue of public health sector neglect is not because of Pakistan’s poor economic situation. Pakistan is a promising country and has spent substantial money on different infrastructural projects for socioeconomic enhancement. The point is that Pakistan is not willing to spend enough on healthcare or to impose stringent regulation to limit the excesses of the private sector. This unequal approach in human development has weakened the social contract between the state and its citizens, reflecting in the people’s declined trust in the government, institutions and each other.

At the time Pakistan is using a control and command model to keep a check on the private health sector. Registration, licensing and standardisation of healthcare services through clinical governance have closed quality gaps considerably. However, the sustainability of this model remains a question mark in view of external ‘inspections’ being periodic in nature and for not providing a continuous quality check approach, which makes easier for healthcare service providers to go back to business as usual, once the review is done with.

One answer to this anomaly lies in dispersing regulatory burden across different stakeholders like professional associations, accrediting institutes and patients themselves. The strategic input for this smart regulatory framework would come from tax-breaks, subsidies, branding, consumer awareness and penalties for non-compliant behaviour.

Another remedy lies in entering into strategic partnership with the private sector. By handing over the management of government hospitals and health centres to private health organisations, and when needed, purchasing from them routine clinical (e.g. laboratory services) speciality (such as cardiac care) or domiciliary services (hospital waste management) can free the public health sector from the burden of financial and administrative mismanagement.

The public-private partnership model has been in the crosshair of Pakistani policymakers, albeit at a slow pace. Not to make it another mole and to avoid conflict of interests, any adherence to the PPP model must include proper pricing analysis, feasibility studies, pre-qualification of bidders, pay for performance mechanism, clear identification of standard operating procedures for the services, UN-supported drug procurement lists and a third-party audit of standards.

With such extensive private sector dominance in the health sector, any idea that chooses to make it flint-hearted would just prove another dud. A combination of budgetary expansion and application of soft skills borrowed from private management can broaden healthcare coverage to make it universal.

It is about changing the outlook and setting priorities right.

Published in The Express Tribune, February 20^th, 2020.

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