The pre-election political party debates relating to their positions on various sectoral processes ofthe state on national television, has prompted many ofus to review party manifestos with the view to exploring strengths and weaknesses in an attempt to determine the deciding edge. Although the process may be indecisive, it leads one to acknowledge thefact that writing a manifesto must not be an easy task as bringing clarity and coherence to a range ofparty positions is a task that demands both strategic capacity and vision within party ranks. Given this, the effort to come up with manifestos, notwithstanding their weaknesses, is a step in a positive direction and shouldform thefoundation to buildfurther based on inputsfrom technical contributions. One ofthe areas that need substantial honing in each ofthe manifestos is health and it is with the intent ofoffering policy inputs into the process that afew non-partisan observations are articulated herewith.
Health has been addressed as a key area in the manifestos ofmost parties; however, the online version ofAwami National Party’s manifesto does not have a section on health. While reviewing each ofthe health sections ofrespective manifestos, one expects a reflection ofseveral aspects – the model ofhealth services andfinancing a party envisages structuring in order to address the current issues in the health sector, their position with respect to their commitment tofund allocation and the priority areasforfund utilization.
First, on the issue ofthe health services model, both PPP and PML-Q come up with the concept of‘National Health Services’ in order to deliver on the healthfor all premise. It must be appreciated however, that a National Health Service, modeled on the Bhore Commission Report of1946 has existed inPakistansince the country’s inception in 1947. Based on the report’s recommendations a three tiered network ofhealthfacilities – which on paper is one ofthe most extensive in the developing countries – has been structured; the problem is that the model doesn’tfunction well. The determinants ofthisfailure are embedded in a complex interplay ofinsufficient governmentfunding to sustain its own health infrastructure and an environment, which enables the private sector to operate in the delivery ofhealth, largely unregulated. When health providers have better incentives to work in the private sector the issue ofdual job holding and absenteeism arises and specialists use their public job leverage to boost private practices; lack oftransparency in governance causes misappropriation oftalent, collusion in contracting and procurement and therefore pilferagesfrom the system and all thesefactors act together to lower the quality ofpublic services.
Countries with welfare systems where health care provision is the responsibility ofthe state, such as in Scandinavia and theMiddle Easthave a very high percentage oftheir budgets allocatedfor health to begin with and their regulatory environments do not let the private sector predominate in health care delivery. Even in resource constrained settings where the level ofcontributions may not be as high such as inCubaandIranbut where the private sector is not allowed to operate, a difference in the quality ofservices is apparent evidenced by their health indicators, which compare much morefavorably.
The solution to these issues is not in prioritizing investments in hospitals as has been stated by most manifestos, but by reconfiguring the mode ofservice delivery. The solution is also not in being coercive with the private sector as they are here to stay but in harnessing their strength throughframeworksfor public-private partnerships in tandem with innovative market harnessing regulatory methods thatfoster quality and can enable the government to leverage the market to deliver health as a public good. This requires major institutional overhaul ofthe Ministry ofHealth and departments ofhealth who need to enhance their capacity in normative and regulatory tasks. Unfortunately none ofthe party manifestos come clearly and coherently on the issue ofa consolidated position on such a health reform, which is badly needed; only one manifesto has referred to the potential ofpublic-private partnerships in passing.
Secondly, service delivery reform has a major bearing on how health is financed and vice versa; in this domain, ofall the manifestos, Tehreek-e-Insaafand MQM have referred to alternative financing mechanisms. However both need revisiting. MQM’s health insurance scheme for all citizens could be an issue given that more than 40% of the citizens work in the non-formally employed sector where lack of a mechanism to make compulsory contributions at sourcefrom salaries would render a universal health insurance scheme unviable. What would have been more pragmatic is to refer to a health insurance schemefor those in theformally employed health sector and social protection and cash transfersfor services in order to offset the risk to the poor in the non-formally employed sector.
Thirdly, is the issue offund allocation. Ofall the manifestos only MQM has alluded to a commitment to increase the health budgetfrom 0.6% to 4% ofthe GDP. Although this is a welcome commitment there are many milestones to be achieved before this can be a pragmatic reality given the limited capacity to expend and utilizefunds in the social sector and limitations to targetfunds effectively. Therefore what is needed in tandem is a clear articulation ofhow reform at a governance level is envisaged to enhance capacity in these areas. Another imperative offund utilization is to ensure that the opportunities to plug leakagesfrom the system are maximized. This has a bearing on anti-corruption and transparency promoting measures. Most manifestos allude to anti-corruption, however the emphasis is on institutional measures and developing mitigates against using institutions as toolsfor political exploitation. What is needed now as part ofpost-manifesto strategic planning exercises isfor clarity and consensus on measures in the administrative and operational domain to implement ethical and administrative codes ofconduct that strengthen the incentives-performance-accountability paradigm.
In thefourth place, a part manifesto has to be reviewed with respect to its position on prioritiesfor resource allocations in health. It is here that thefocus on creating more state supported infrastructure and hospitals and MCH and trauma centers in ‘every district’ as mentioned by MQM, PML-Q, PML-N and PPP in different parts oftheir manifestos is worrisome. There is no dearth ofpublic sector hospitals in the country; however most ofthese are unsustainable and inefficient and have management issues; therefore before consideringfurther investments in infrastructure, structural reform ofthe existing institutions is needed. Again only one manifesto refers to the word ‘hospital autonomy’ in passing, which is one ofthe many measures that can be used to make existing hospitals sustainable.
On a similar note, priority commitments to invest in high-cost technologically-advanced equipment as referred to by one manifesto must be reconsidered as that would take thefocus awayfrom prevention ofdiseases, which is more cost effective. Ofall the manifestos, PML-N and Tehreek-e-Insafallude to prevention in some detail. However, it may have been best toframe prioritiesfor prevention based on an objective assessment ofneed and potentialfor preventability. According to the Federal Bureau ofStatistics, 56% ofthe deaths are now due to non-communicable diseases (heart diseases, cancer, and diabetes); none ofthe manifestos refer to the needfor developing a prevention and control program to address this challenge. One manifesto refers to supporting tertiary carefor these diseases in the private sector; clearly this has to be low on the list ofpriorities. Within the prevention domain and as a cross cutting social sector theme, many manifestos have alluded to safe water but with the samefocus ofsetting upfiltration plants as is presently being done. Safe water needs cannot be met withfiltration plants alone and have to be locally determined in rural and urban areas. For example, in rural areas needs are predominantly shortage-related and can be amenable to locally-developed solutions such as infrastructure investments on making storage tanks, hand pumps and check dams, as the case may be, based on geographic considerations. In the urban areas,for example, a number ofmeasures such as changing corroded pipes and addressing sewerage leakages into broken pipes and issues ofland use may be the solution. Party manifestos have not placed due emphasis on these measures.
Lastly, two ofthe manifestosfocus on telemedicine and one ofthemfocuses on promoting telemedicine in ‘every district’; here caution needs to be exercised as promoting telemedicine without attention to issues relevant to the availability ofcommunication infrastructure in remote areas where telemedicine is actually needed and more importantly, provider buy-infrom the standpoint ofincentives can lead to investments without corresponding outcomes. On the other hand, there are other uses oftechnology such as in health information systems, reducing costs and medical errors, e learning, continuing medical education and tracking ofrecords to promote transparency within the system, which are more effective and must receive due attention.
There is a reasonfor using health as an insight into manifestos. Health and education should be one oftheforemost priorities ofthe state as they are a true sign ofa country’s development. Health issuesfeature prominently in all pre-poll political debates particularly in the developed world as is evidenced by the current political process in the United States; given the size ofthe challenge in our country, and the complexities ofthe envisaged reform, one would hope that parties set their priorities and directions right.
In these tumultuous times, the winning party(ies) in the election will have many issues to grapple with and planning within the social sector may not seem as urgent as many other political, security and macroeconomic issues. Notwithstanding, certain strategic directions must be determined; the substance within these directions will not only determine how serious the new government is in addressing problems in the social sector, but will also indicate their sincerity to the cause of improving lives of the poor – a catchphrase they use to win elections.