The healthcare system of Pakistan - a story of corruption and betrayal

According to the official version Pakistan is supposed to have one of the best healthcare systems in the world. This shows what barefaced liars there are in the state. We all know that in practice it is one of the worst and the shift to private healthcare is making it even worse. Dr Ahmad Arslan and Dr Abdullah reveal the real state of affairs. They show how the Pakistani government is merely a tool in the hands of the multinational drug companies who have no interest in genuine healthcare. Their primary concern is profit.

According to the official version Pakistan is supposed to have one of the best healthcare systems in the world. This shows what barefaced liars there are in the state. We all know that in practice it is one of the worst and the shift to private healthcare is making it even worse. Dr Ahmad Arslan and Dr Abdullah reveal the real state of affairs. They show how the Pakistani government is merely a tool in the hands of the multinational drug companies who have no interest in genuine healthcare. Their primary concern is profit.

After partition Pakistan inherited a totally inadequate health care system comprising only of one medical college and a few practicing doctors, (a few civilian and military set ups also existed but these were not sufficient). Over time the system was expanded and now it has spread nationally. The system is divided into two, the public sector and the private sector.

With some exceptions the major health needs of the public are catered for by the public sector. The major infrastructure of the public health care system was set up in the 1970s by Zulfiqar Ali Bhutto’s People’s Party government, which had clear socialist inclinations. Pakistan had also endorsed the then Moscow driven "health for all by 2000" initiative which had been launched by the World Health Organization. The socialist orientated People’s Party government launched an extensive infrastructure and policy building initiative.

From the villages to the cities different levels of health care were started like the "Basic health units" for the villages. The Tehsil headquarter hospital represented secondary health care, and district hospitals and teaching and referral units represented tertiary care units.

Along with this a significant public health campaign was launched for the first time, keeping in view local needs and WHO guidelines to meet the target. These were: An expanded programme of immunization to eradicate the prevalent infectious diseases; Malaria control programme; Tuberculosis control programme; Family planning programme; Diarrhoea and pneumonia control programmes; and many others. To monitor all these and to achieve further improvements and make sure the policy was being applied the national institute of health was created.

The People’s Party government collapsed due to a number of reasons. The main reason was that it was trying to carry out its reforms within the confines of the capitalist system. Because of its straying from the revolutionary path and with the help of imperialist intervention it was eventually brought down. In spite of this it laid down the basic infrastructural healthcare plan which was to be followed by the successive governments of Pakistan.

Of course these governments had no socialist inclinations. Rather their aims were the opposite – to defend the rich minority at the expense of the poor masses. Thus although subsequent governments, like Zia’s, built major health complexes they completely failed to deliver to the people what they really needed. The basic healthcare units built in large numbers were in far flung places where there was very little population and the support structures, such as schools and residences were never built so doctors and other medical staff never wanted to work there. They existed as ghost units.

Nevertheless under every government the "health for all by 2000" remained official policy for the state-owned health system. And despite all the corruption and mismanagement it provided a big relief to the people of Pakistan.

Private health sector

Although it was the public healthcare system that was providing the greatest relief for the poor, it was precisely this sector that each successive government has tried to undermine. Especially under general Zia, the public sector entered a period of decay, when ghost units were being built to siphon funds away from the state to private contractors. Thus the private sector became increasingly active. His government systematically destroyed the public sector, especially in healthcare. This was a deliberate policy. A dilapidated public healthcare system prepared the ground for introducing private healthcare. The idea was that instead of protesting, the public would thank him.

Thus we had the emergence of rampant corruption in the public sector, which contributed to a worsening of the service provided. In the meantime a vibrant private healthcare sector flourished like mushrooms. Now a parallel healthcare system exists in Pakistan. It is efficient and equal in standard to anything in the west but as it is run on purely business lines it has no ethical values. It is totally unaffordable for the general public and has become one of the most successful businesses in Pakistan. The policies of all successive governments have been to destroy the public healthcare system and favour the private sector.

Education

As described previously, after partition West Pakistan only had one medical college, the King Edward medical college in Lahore. Later on the Nishtar medical college was set up in Multan. During the Ali Bhutto government a policy was adopted to increase the number of medical colleges, some of which were actually built while Bhutto was still in power and some were built by the subsequent regimes. As the plans of the Ali Bhutto government were subsequently taken up by those who did not believe in them, the whole of the public sector suffered from corruption and mismanagement. This was also consciously favoured by the government, as it played a role in undermining the ideas of nationalization and planned economy.

The standard of education in these colleges was maintained to some extent due to the hard work of the doctors, but they never really enjoyed government support. In order to maintain the high standards of medical training the Ali Bhutto government had improved and revitalized the Pakistan Medical and Dental Council (PMDC). During the subsequent decades it also became a token institution used merely to reward loyal people with well-paid jobs. This demonstrated once again that without a full socialist system to back them up, semi-socialist policies are unsustainable. Now the government has allowed the setting up of private medical colleges with the excuse of improving medical training as the public sector institutions are inefficient and corrupt. We will deal with this separately.

Pharmaceutical sector

Pharmaceuticals are one of the worst sectors in the healthcare scene of Pakistan. It is the monopoly of a few giant pharmaceutical multinational brands that exploit the poor people of Pakistan and the present government is fully supporting this in the name of the sacred "free market economy". Soon after the deregulation of the industry by the Nawaz Sharif government the prices of drugs multiplied a hundred times. The multinationals are raking in as much as 500 times the actual cost of production of some medicines. The safe and tested drugs, which are on national and international essential drugs lists, are usually withdrawn from the market so that expensive alternatives can be sold. Many cheap life-saving drugs are constantly in short supply. The prices of some drugs are so high that even the middle class can’t afford decent antibiotics. Dangerous and irrational drugs that have been banned in the West are sold in Pakistan. Local doctors are misled by the pharmaceutical companies to prescribe junk drugs. And the government remains silent and allows this to go on so as not to offend the WTO and the icon of "free trade".

During Ali Bhutto’s government this policy was analysed and the problem was identified. It was agreed that drugs must be cheap and affordable. In order to achieve this goal the veteran socialist MP Sheikh Rasheed Ahmed, the Minister of Health introduced the famous and radical Generic Drugs Ac which was aimed at breaking the back of the multinational monopolies and actually managed to bring the prices down to a very low level. The problem with this reform, as with all the others, was that, as the capitalist system was not transformed completely, it was soon to be reversed.

In spite of this even the subsequent government managed to maintain some degree of control over the prices. This, however, was lost when the Nawaz Sharif government signed the WTO free trade treaties. After the endorsement and introduction of the notorious T.R.I.P.S (trade and intellectual property rights) it has now become impossible to produce cheap generic drugs. The fate of the whole of the so-called Third World has been doomed by "free trade"!

Current scenario

As we have already explained, traditionally it had been the policy of the government - on paper at least - to provide free health care. This all changed under the regime of Nawaz Sharif, when Pakistan officially endorsed the free trade WTO treaties. Mr Sartaj Aziz in his policy address to the national assembly announced that from then onwards the government of Pakistan would divest itself of any state property and that everything would be privatised.

Over the last decade each government has been slowly moving towards this goal and trying to make this transition as smoothly as possible. The first step was to highlight the inefficiency and mismanagement of the public sector hospitals. Some high profile cases of mismanagement were publicised in the media and thus the public was brought round to the idea that private would be better. The cure the disease of public mismanagement was said to be "discipline and autonomy". Many welcomed this as they thought an improvement could be achieved by these means.

However, soon the government’s intentions were made clear. In the name of "autonomy" the hospitals were asked to maintain their budget by themselves. The result was an increase in the cost of tests and treatment. Free test were withdrawn and there was a marked increase in service charges. The whole point was to convince the public that they did not need big overcrowded government hospitals which were "costly and inefficient". They would be able to get better services from private hospitals by paying only slightly more money. The slogan was "cost for efficiency".

As all these measures were bound to create unrest among the doctors, freedom to hire and fire was granted to the "autonomous" hospitals. A board of governors was created for each of these hospital bringing it directly under the control of the provincial secretary. Other board members were taken from representatives of the capitalist class such as mill owners. These were made familiar with the workings of a hospital, putting them in a position whereby they could take part in the bidding process.

In the medical staff education and training sector the same policy was adopted. Many private medical colleges were allowed to work without reaching the standards set internationally. The PMDC has been transformed into a docile obedient institution. The medical colleges are now charging anything between 1.5 and 2 million rupees for graduation in medicine. Also the fees in the public sector medical schools have been increased to bring them more in line with the levels charge in the private sector. This is so people will feel there is no difference when they are eventually sold off to the private sector.

University of Health Sciences

To get greater control over the future of the students, the government thought up of a stunt. They created the University of Health Sciences and all the medical colleges in the Punjab were asked to affiliate to it. Interestingly the elite colleges such as the King Edward and the Fatima Jinnah medical colleges were exempted from doing so. This "university" is not recognised internationally and it can destroy the careers of medical students whose degrees will not be accepted abroad. The sole purpose of this operation was to centralise the results and examination system so that if any students were to rebel against privatisation they could easily be victimised directly from the central "parent school" in Lahore.

The inadequate private medical colleges that do not fulfil the requirements of other universities could easily get recognition through this dummy "university" which actually lacks any facilities of its own!

Part of the government’s manoeuvring has also involved an attempt to increase ethnic tension between the southern and northern Punjab so as to divert the attention of the people away from these problems and thus confuse them and stop them from adopting any progressive thinking.

Student revolt

The general Zia regime and all subsequent regimes have attempted to stifle any kind of political activity in the colleges. It was in fact totally banned. Student unions are still banned to this day and after the experiences of the past the people, and especially the students had developed apathy and hatred towards "politics". But when the government started to actually implement the above-mentioned steps, such as the increase in fees and the setting up of the "University of Health Sciences", the student spontaneously protested. Student strikes took place in some colleges for the first time in twenty years!

It has to be said that initially the students clearly lacked any political motivation. Years of political inactivity and repression had imbued them with not such a progressive. But this was now about to change. This protest was the first step towards breaking the code of silence and fear. Students are now clearly moving towards some form of political orientation. This movement is in its early stages and reveals all the weaknesses of lack of experience and leadership. Sometimes the students even use reactionary and passive forms of resistance to try and win some concessions. But as they do not understand the real motives that lie behind these measures and do not apply the correct tactics they fail.

However all experiences teach, and as time passes the movement will clearly take a progressive turn. We have carried out some political work among the students and have achieved some great results. This shows that this movement could be the first step towards a more general politicisation of Pakistani workers and youth. The students have learnt one thing: for the first time they have seen how important resistance is. Although minor, they were able to win some concessions by standing up to the authorities. Soon they will understand the limits of their methods adopted so far and will move to the left. We are constantly working toward this goal!!!

"Inefficient public sector"!

Currently a lot of hue and cry is being made about the so-called inefficiency of the public healthcare system. The government claims that state ownership is to blame!! The truth is that it is inefficient because the government wants it to be inefficient in order to more easily get rid of it! How can any healthcare system be efficient when the money allocated to it in the state budget amounts to only 0.7% of GDP when it should be at least 4 to 6%?

Where there should be one nurse for every four patients there is only one for every 40 in tertiary care hospitals. Where there should be one doctor for every seven beds, there is only one doctor for every 60 beds! A doctor should only have to work an 8 hour shift, but doctors usually have to work between 36 and 72 hours in a single shift, mostly unpaid!! To add to this, the recruitment of doctors has now been banned for more than 20 years.

How could a system be efficient in these conditions? Instead of giving long awaited jobs, millions of rupees are spent to create boards of governors and dummy universities. In a country where 70 out of 1000 newborn children die and 60 mothers out of 1000 die during childbirth, the lion’s share of the national income goes on buying weapons! The majority of people and especially children die of diseases that are totally curable and preventable such as diarrhoea, pneumonia, tuberculosis, etc.

In a country where most people earn less than 3000 rupees per month we have medical colleges charging between 1.5 and 2 million for a medical graduation. However, awareness is growing and the people are now beginning to understand the true nature of capitalism.

Long live the revolution!