he planet earth’s environmental and ecological transformation is a subject of much ado as are the contemporary concerns around the power dynamics, which will determine the global epicenter economically, militarily and politically over next two to three decades. This is justifiably a subject of critical thinking and planning. But sadly, the implications of this makeover for the social sector remain largely unrecognized. In the health sector more specifically, the thinking that health needs to be delivered as a public good – modeled on the Alma Ata ethos – still holds ethical merit backed by constitutional legitimacy and state commitment as in many developing countries; this model is also being followed in Pakistan where the delivery of health is seen as a state prerogative with the state attempting to provide health for all. How the booming market dynamics play into this calculation, how vested interests, profit margins and the omnipresent role of the private sector cut across this paradigm, how a globalized world impacts access and affordability issues in health and how urbanization and an aging population necessitate new demands for health care is seldom a focus of attention. It is time that these considerations are a focus of concerted planning or else health will fail to reap the benefits of economic growth on whichPakistanappears to have set forth recently.
There are several reasons why the health sector needs conceptual restructuring.
Firstly on issue of the viability of the state-delivery-of-care-model, it must be understood that broader changes in the macro-economy and the emergence of the private sector as the engine of growth have also led the private sector to offer what is regarded as ‘social services’ by the State – albeit at a cost. We are aware that the level of incentives to offer care in the private sector have led to the institutionalization of dual job holding by health professionals; these considerations have systematically undermined the State’s health service delivery infrastructure: basic health units do not function because of a lack of motivation to operate them and hospital high tech equipment is often out of use because of lack of incentives to operate them. On the other hand, quality issues notwithstanding, we see the private sector – infrastructure as well as human resources – booming and delivering care in the market for a cost in an environment which is largely unregulated.
Secondly, globalization has brought in its wake many contemporary challenges. The technology boom and the speed and access to interconnectedness has created a huge opportunity for capacity building, streamlining quality and efficiency in the delivery of care and management, and knowledge sharing but on the other hand also the risks of spurring costs as a result of over-utilization especially in the unregulated private sector. Liberalization of trade under WTO in a globalized community brings its own access and affordability issues particularly in terms the affordability of newly discovered medicines and under GATS, the mainstreaming of the market mechanism in the delivery of care in a manner that is detrimental to the interests of the marginalized, is a potential threat. In a globalized world, pandemics are known to spread with relative ease as have the SARS and Avian flu epidemics shown and mass damage by biological weaponry and humanitarian crises as a result of conflict and acts of terrorism are known to have health implications.
Thirdly, over the years, evidence has shown that health is not all about what the health sector can deliver. For instance, the most successful intervention to reduce child mortality is not related to the number of hospitals or doctors but investments in the mother’s level of education; the most effective intervention to reduce tobacco related morality is tax, tarrif and price related and the most effective intervention to reduce childhood diarrhea is in the municipal and not the health domain.
And lastly, demographic and epidemiological transitions in health are known to reshape the way disease patterns will affect populations and the manner in which population subgroups will be affected, raising concerns about the current priorities for resource allocations.
How should the health sector be responsive to these realities and what should the role of the state be then over the next two to three decades? Should it attempt to continue to act as a part-financier, part-provider and quasi-regulator of health services or should it relinquish control of the role of being the provider and enhance its capacity to regulate a market, which has every intention of growing, regardless? Should it operate a “health care” paradigm or should it broaden its scope within an inter-sectoral ambit and focus on the inter-disciplinary responses as well. Should it focus on improving health outcomes through a focus on doctors, hospital beds, and other health care outputs or should it address health within a broader international and national policy context. Clearly the choices are and should be clear. The logical next question is how to respond and what works then?
Over the years we have learnt that coercive responses to this reality are not going to work; amongst other things, this has also been recently demonstrated by the failure of institutional based private practice in NWFP; we have also seen that the adhoc institution of measures such as contracting out models seem to generated a widespread outcry and controversy with issues of acceptance and turf battles. It is therefore clear that piecemeal solutions to a paradigm which has completely changed will not be sufficient; this underscores the need to ‘play health with a new stack of cards’. We need to define new norms and standards, redefine the role of the state in the provision of care, strengthen its ability to regulate, broaden the base of the civil service reform process to a public sector reform process alive to these realities; enable the creation of frameworks that both regulate and facilitate the private sector and create strong institutional frameworks to offset the risk to the poor and disadvantaged in an environment where health is being increasingly sold for a cost. It is here that the responsibility for redefining the ‘rules of the game’ fall on initiatives such as the recently launched Vision 2030 – a valid foresight exercise of the Planning Commission of Pakistan designed to assist in defining the needs of a future Pakistan. The program gives due prominence to health through its ‘prosperous society sub-theme’ on health care and social sector. It is hoped that this initiative will articulate, strategic directions to address the aforementioned issues. However as always, the challenge then would be to ensure these get concretized into implementation – in letter and in spirit.