Written by Dr Ahmad Arslan

The battle for universal health access for every Pakistani can only be won through joining it with the struggle for a socialist transformation of the society. So it is time for the doctors and nurses to join the struggle because now it’s the struggle to save the medical and healthcare system as well.

Photo by Gul Hamaad Farooqi

Pakistan has become a country of endless crisis. Crisis is perhaps the most heard and spoken word on national television in Pakistan these days. From sugar crisis to rice crisis, people of Pakistan are frustrated and unable to understand why in an agricultural country, with some of the best fertile lands in the world and some of the best harvest in recent years, according to the government’s own proclamation, they can’t get flour, sugar and rice from the market even at triple prices. Sugar for example is not available even at 100 or 150 rupees per kilogram. Its usual price ranged between 20 to 30 rupees. The government and Supreme Court fixed it at 40 Rs. This despite the fact that Pakistani farmers produced the best sugar cane crop last year and according to various economists there is no production shortage of sugar in the country. There is a very simple explanation for all of this, one which Pakistani intellectuals and political analysts don’t want to hear and that is: “It’s Capitalism!” Its the wonders of capitalism where you can produce the best of wheat and sugar cane and still can’t find sugar and flour in the market. The crisis which I am going to discuss has a similar color to it where you can produce some of the finest doctors and nurses in the world but have one of the worst health care systems.

Some Background Information

Pakistan is a country which has an organized, structured and planned health care system, at least in theory and on government papers. Most of it is in a state of organic decay which is the result of bureaucratic incompetence and red tape. A very important cause of this decay is the deliberate and conscious assault on the Public Sector health care system by the ruling elite of Pakistan in the name of “reform”, “devolution” and “de-regulation”. These reforms have destroyed not only the health care system but have also created a crisis in areas like medical education and specialist training thus threatening the very survival of health care system in the country.

From the very start Pakistan had two parallel health care systems, public and private. The private sector’s share in health care was very small. Most of it consisted of the private practice of doctors in their communities. Initially this private practice was part-time and not very expensive. The bulk of health care existed in the Public sector. It was organized in the late 60s and early 70s especially after Pakistan People’s Party first government came to power on a socialist program. The public health care system was organized in 3 layers which were hierarchical. A network of Basic Health Units was envisioned and later built to serve the community at grass roots level. The BHUs existed at the level of villages and were concerned with “Primary Health Care”. They were also to be the basic vehicle for the Public Health Campaigns, like conducting mass immunization programs (Started in first PPP government), Malaria, Tuberculosis and Diarrhea control programs, programs for reproductive health, contraception and family planning. At the level of towns and small cities, a network of secondary health care units was set up which acted as centers for basic specialist care and supervisors of BHUs. At the top of the chain was “Tertiary Care System” or centers of advance specialist care, teaching hospitals, research centers and medical colleges.

To regulate and monitor various aspects of health care system regulatory bodies were made. Pakistan Medical and Dental Council or PMDC is the primary watchdog and regulator of medical education and practice, modeled on the General Medical Council of the United Kingdom. College of Physicians and Surgeons Pakistan or CPSP (modeled on Royal College of Physicians and Surgeons UK) regulates the teaching hospitals and is concerned with specialist and post-graduate medical education. National Institute of Health is concerned with Public Health. .

A complete and organized service structure was provided from being a medical officer in a BHU to being a professor of medicine at teaching hospital through Public Service Commission and MoH.

Pakistan also committed itself to “Health for All by Year 2000” initiative. It was a Moscow driven United Nation campaign in which the signatory nations pledged to provide universal health care to their people by year 2002. Now its 2009 and people still await the universal health care promised to them by their states. Most of this was happening in the 60s and 70s when a strong socialist movement existed in the country which was forcing the governments to do something about the health sector. The reconciliatory policies of Zulfikar Ali Bhutto led to the reactionary dictatorship of Zia-ul-Haq who corrupted and mismanaged the public sector opening the way to the private sector. Large private hospitals started to appear and the regulations on the pharmaceutical sector were removed. In the 90s Pakistan went into full “de-regulation” swing. During Musharraf’s time the private sector was given complete parity with the public sector with deliberate strangulation of public sector medical education.

The Myth of efficient Private Sector: Where is the Improvement?

Since the time of General Zia-ul-Haq a deliberate myth has been built by the politicians, governments, NGOs and certain intellectuals that the private sector is very efficient. By opening up the health sector to private investment, the public’s access to quality health care will increase. With the private sector, professional standards will improve. Tales of medical negligence and malpractice in public hospitals were propagated in mass media. There is no question that there were inefficiencies and shortcoming in the public sector (which itself was due to bureaucratic corruption) but the mania that was created was totally out of proportions.

As a result of these and government policies we saw a mushrooming of private medical hospitals throughout Pakistan. Some of them look like European Plazas with lavish rooms similar to those of five star hotels, having huge LCD screens to watch television. Contrary to all myths there was neither improvement in professional training nor professional standards. The standard of care actually deteriorated, medical malpractice reached new heights and the media filled up with reports of terrifying tales of corruption and exploitation in the private sector hospitals. The cost of health care increased thousand folds or so. On the top of it there are constant reports in the media on the development of illegal and unethical trade of “transplant organs” within the private sector hospitals. Exploiting the poverty of the people, these hospitals buy kidneys and other organs from the patients sometimes even without their consent. Cases have been reported where both kidneys of a patient were removed on pretext of doing an operation for appendicitis; Pushing the person towards a certain death.

There are horrifying stories regarding the Cosmetic surgery clinics and fertility clinics (which have mushroomed in the past decade). Their practice is totally unregulated and highly unethical in most situations. A similar unregulated medical business exists in form of controversial laser treatment and surgery to improve the eye sight. In most cases these businesses are not in the hands of doctors and there are reports that procedures are done by non medical technical staff (It’s not a mainstream medical practice).

Also private medical colleges and universities are mushrooming in the country, which have no proper teaching staff and hospitals and are producing incompetent doctors although extracting exorbitant fees from their students.

It needs 2 to3 million Pakistani rupees ($35,000 approx.) and five years for a student to become a medicine graduate in private hospitals. Also the situation in public medical colleges is not encouraging with one to a few hundred student:teacher ratio the standards can be understood easily.

Also the situation in public hospitals is miserable. Patients being treated in cruel ways and in hazardous premises only leads to more disease and illness. Corruption of management in public hospitals is a normal practice with selling of drugs to medical stores, embezzlement of funds, taking commissions from private medicine companies, defecting medical equipment by staff and other irregularities.

Even a bed in a public hospital is on sale, whoever pays the bribe can be admitted.

So millions die here without reaching the proper hospital and many die after reaching the hospital as they have not enough money to get treatment and to pay bribes. Also many die even in the hospital due to negligence and improper care.

Many cases of deaths due to negligence have been reported even in expensive private hospitals.

Facts Speak For Themselves

With active strangulation of the public sector and mushrooming of private hospitals, what is the actual improvement?

Pakistan ranks 136 out of 177 countries in the Human Development Index (United Nations 2007/2008). The index is based on social and health indicators of a country, putting Pakistan amongst the poorest.

According to Dr Mehboob-ul-Haq, from the center of human development, 73% of the Pakistani population lives below the poverty line despite the unprecedented “growth” due to economic liberalism (Dr Mehboob-ul-Haq was a capitalist economist and economic minister of Zia-ul-Haq).

In the 10 year review of the social and health indicators and economic growth in South Asia by the center in form of “Human Development in South Asia” published last year, it was noted that “The progress of life expectancy in Pakistan in last 10 years is slowest in the region”

The percentage of malnourished children under five years of age remains stagnant at 38%

The maternal mortality rate per 100,000 live births actually increased from 340 deaths in 1993 to 500 deaths in 2000. (Please note this is the time period of most active de-regulation and economic liberalism and booming of the private health sector in Pakistan)

Incidence of Tuberculosis per 100,000 populations increased from 150 in 1995 to 181 in 2004.

Public Spending on health came down from 0.8 % of the GDP in 1995 to 0.4% in 2004

There is general deterioration or stagnation in every social and health indicator, thanks to the Capitalist neo-liberalism and economic growth.

The ratio of doctor to population is 1 to 1254. Even today 80% of all deaths and 90% of all illnesses in Pakistan are due to diseases which are preventable.

Thanks to rotten capitalist policies of the ruling elite of Pakistan today’s 80% of total health care expenditure is private expenditure and that too is in the form of “out-of-pocket” money. In a country where 73% live on less than 2 dollars one can imagine how hard it is to get health care.

A Comparison with Cuba: Miracles of planned health care

Although I don’t consider Cuba an ideal socialist republic, the overthrow of capitalism and a planned health care system and economy has done wonders in terms of human development. Cuba is a tiny country with scarce resources as compared to Pakistan. At the time of the Cuban revolution, there was a mass exodus of doctors from Cuba to United States. Only 3000 doctors and 16 medical professors were left in Cuba,

Castro started a program of nationalization and regionalization of health care in the 1960s. Emphasis on preventive rather than curative treatments was given; now there are 66,600 doctors, 83,800 nurses, its density of doctor to population is 5.91, better than the USA and the UK.

Life expectancy in Cuba is at par with the developed nations and infant and maternal mortality rates lowest. The Cuban government operates one of the largest, if not the largest, medical school in the world, the Latin American School of Medicine. Cuban doctors are providing services in Venezuela and other fraternal countries. After the disastrous earthquake in Pakistan in 2005 Cuba sent the largest aid contingent there were around 2,600 medical personnel, which included 1,430 doctors, sent to treat the earthquake-affected people from Cuba.

Cuba also donated 30 mobile hospitals and a large quantity of medicines and equipment to Pakistan. These medical personnel not only lived with the affected people in the same surroundings but stayed on longer than other medical professionals from different countries. This is in sharp comparison to the traditional friends of Pakistan’s ruling elite like the USA and Arab countries.

The Cuban health care system has been declared better than that of USA and UK in terms of Universal Access. Cuba built all this while facing a continuous American Embargo while Pakistan has always been receiving “aid” from USA.

Stop the Private Sector and Save the Public Sector

The only solution to the crisis of health care and the intolerable cost of caring for the sick is to stop making health care a business. It is time to stop the Privatization of the health sector, and increase the investment in the public sector.

The defense budget must be cut and spending on health increased and new hospitals and medical colleges should be opened in the rural and backward areas.

Priority must be given to Primary Health Care and Preventive Medicine.

Immediate end to the contract system and restoration of Public Service Structure for the Doctors and Nurses

Complete rejection of the present People’s Party government program of “Public-Private Partnership” which is nothing but privatization in disguise

The battle for universal health access for every Pakistani can only be won through joining it with the struggle for a socialist transformation of the society. So it is time for the doctors and nurses to join the struggle because now it’s the struggle to save the medical and healthcare system as well.