Published in The News International on February 16, 2008:
The pre-election political party debates relating to their positions on various sectoral processes of the state on national television, has prompted many of us 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 the fact that writing a manifesto must not be an easy task as bringing clarity and coherence to a range of party 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 should form the foundation to build further based on inputs from technical contributions. One of the areas that need substantial honing in each of the manifestos is health and it is with the intent of offering policy inputs into the process that a few non-partisan observations are articulated herewith.
Health has been addressed as a key area in the manifestos of most parties; however, the online version of Awami National Party’s manifesto does not have a section on health. While reviewing each of the health sections of respective manifestos, one expects a reflection of several aspects – the model of health services and financing a party envisages structuring in order to address the current issues in the health sector, their position with respect to their commitment to fund allocation and the priority areas for fund utilization.
First, on the issue of the health services model, both PPP and PML-Q come up with the concept of ‘National Health Services’ in order to deliver on the health for all premise. It must be appreciated however, that a National Health Service, modeled on the Bhore Commission Report of 1946 has existed in Pakistan since the country’s inception in 1947. Based on the report’s recommendations a three tiered network of health facilities – which on paper is one of the most extensive in the developing countries – has been structured; the problem is that the model doesn’t function well. The determinants of this failure are embedded in a complex interplay of insufficient government funding to sustain its own health infrastructure and an environment, which enables the private sector to operate in the delivery of health, largely unregulated. When health providers have better incentives to work in the private sector the issue of dual job holding and absenteeism arises and specialists use their public job leverage to boost private practices; lack of transparency in governance causes misappropriation of talent, collusion in contracting and procurement and therefore pilferages from the system and all these factors act together to lower the quality of public services.
Countries with welfare systems where health care provision is the responsibility of the state, such as in Scandinavia and the Middle East have a very high percentage of their budgets allocated for 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 of contributions may not be as high such as in Cuba and Iran but where the private sector is not allowed to operate, a difference in the quality of services is apparent evidenced by their health indicators, which compare much more favorably.
The solution to these issues is not in prioritizing investments in hospitals as has been stated by most manifestos, but by reconfiguring the mode of service delivery. The solution is also not in being coercive with the private sector as they are here to stay but in harnessing their strength through frameworks for public-private partnerships in tandem with innovative market harnessing regulatory methods that foster quality and can enable the government to leverage the market to deliver health as a public good. This requires major institutional overhaul of the Ministry of Health and departments of health who need to enhance their capacity in normative and regulatory tasks. Unfortunately none of the party manifestos come clearly and coherently on the issue of a consolidated position on such a health reform, which is badly needed; only one manifesto has referred to the potential of public-private partnerships in passing.
Secondly, service delivery reform has a major bearing on how health is financed and vice versa; in this domain, of all the manifestos, Tehreek-e-Insaaf and 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 source from salaries would render a universal health insurance scheme unviable. What would have been more pragmatic is to refer to a health insurance scheme for those in the formally employed health sector and social protection and cash transfers for services in order to offset the risk to the poor in the non-formally employed sector.
Thirdly, is the issue of fund allocation. Of all the manifestos only MQM has alluded to a commitment to increase the health budget from 0.6% to 4% of the 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 utilize funds in the social sector and limitations to target funds effectively. Therefore what is needed in tandem is a clear articulation of how reform at a governance level is envisaged to enhance capacity in these areas. Another imperative of fund utilization is to ensure that the opportunities to plug leakages from 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 tools for political exploitation. What is needed now as part of post-manifesto strategic planning exercises is for clarity and consensus on measures in the administrative and operational domain to implement ethical and administrative codes of conduct that strengthen the incentives-performance-accountability paradigm.
In the fourth place, a part manifesto has to be reviewed with respect to its position on priorities for resource allocations in health. It is here that the focus 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 of their manifestos is worrisome. There is no dearth of public sector hospitals in the country; however most of these are unsustainable and inefficient and have management issues; therefore before considering further investments in infrastructure, structural reform of the existing institutions is needed. Again only one manifesto refers to the word ‘hospital autonomy’ in passing, which is one of the 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 the focus away from prevention of diseases, which is more cost effective. Of all the manifestos, PML-N and Tehreek-e-Insaf allude to prevention in some detail. However, it may have been best to frame priorities for prevention based on an objective assessment of need and potential for preventability. According to the Federal Bureau of Statistics, 56% of the deaths are now due to non-communicable diseases (heart diseases, cancer, and diabetes); none of the manifestos refer to the need for developing a prevention and control program to address this challenge. One manifesto refers to supporting tertiary care for these diseases in the private sector; clearly this has to be low on the list of priorities. Within the prevention domain and as a cross cutting social sector theme, many manifestos have alluded to safe water but with the same focus of setting up filtration plants as is presently being done. Safe water needs cannot be met with filtration 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 of measures such as changing corroded pipes and addressing sewerage leakages into broken pipes and issues of land use may be the solution. Party manifestos have not placed due emphasis on these measures.
Lastly, two of the manifestos focus on telemedicine and one of them focuses on promoting telemedicine in ‘every district'; here caution needs to be exercised as promoting telemedicine without attention to issues relevant to the availability of communication infrastructure in remote areas where telemedicine is actually needed and more importantly, provider buy-in from the standpoint of incentives can lead to investments without corresponding outcomes. On the other hand, there are other uses of technology such as in health information systems, reducing costs and medical errors, e learning, continuing medical education and tracking of records to promote transparency within the system, which are more effective and must receive due attention.
There is a reason for using health as an insight into manifestos. Health and education should be one of the foremost priorities of the state as they are a true sign of a country’s development. Health issues feature 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 of the challenge in our country, and the complexities of the 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.
The author is the founder president of a health think tank, Heartfile. Email firstname.lastname@example.org