BY MAHRUKH SHAHID

Earlier this year, the Prime Minister (PM) of Pakistan, Nawaz Sharif, launched a state-run health insurance program called the Prime Minister’s Health Program (PMHP). The scheme initially targeted 15 districts, but PM Sharif quickly announced plans to expand PMHP to 23 districts and expressed hope that the program would soon become available in all 128 districts, plus the seven tribal agencies of the country.1 Under this program, the PMHP will issue special cards to families in need, providing them with USD 2,865 per year for free treatment.1 The government will pay for the insurance from its own coffers. PM Sharif highlighted his motivations behind the program by describing PMHP as the first step towards making Pakistan a welfare state.1 However, several features of this endeavor may prove problematic, including its severely restricted scope. In order to fully evaluate PMHP, we must consider the larger picture at hand and how the issues plaguing PMHP fit into the history of failed healthcare reform in Pakistan. Furthermore, a comparison between healthcare in Pakistan and Brazil—a country that has recently made major strides towards a universal, integrated, and accessible healthcare system—will hopefully contribute further perspective on the nuanced issue of healthcare policy and reform.

The histories of Pakistan and Brazil bear two very noticeable commonalities: the marks of colonialism and dictatorship. Both countries have been ruled by superpowers who aimed to exploit their resources for maximum economic gain. After achieving independence, the two nations have both struggled with political upheavals, and fights for the right to democracy.2,3 When it comes to healthcare, Brazil’s civil society used the struggle for democracy to institute health as a basic human right and duty of the state, but in Pakistan, widespread mobilization of the common people around this basic necessity has failed to occur. Even in 2016, healthcare reform is initiated at the behest of the political leadership, with questionable political motives, instead of a grassroots movement. A comparison of these two countries demonstrates that Pakistan’s top-down model is less effective than Brazil’s mass mobilization for the issue of health.

In 1988, the Brazilian constitution recognized health as a basic right, resulting in the creation of the Unified Health System (SUS). The SUS provides and finances health services at the federal, state, and municipal levels. The healthcare reform that inspired the SUS was “driven by civil society rather than by governments, political parties, or international organizations.”2 This movement joined forces with the struggle to restore democracy in the late 1970s, and its ability to combine different societal initiatives gave the movement widespread influence. Middle class populations, trade unions, illegal left-wing parties, health professionals and professors, and grassroots movements all joined forces to present a unified front.2 In the face of stiff resistance from a strong, organized private health sector, the health reform movement gained approval for reform from the National Constituent Assembly of 1988 and, despite political upheaval during the next decade, the government successfully implemented the SUS and various other initiatives, such as the National Tobacco Control Program.2,4

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This picture depicts a rally from the 2013 protests in Brazil, which were aimed at increasing government effort and funds to improve key services including public education, national health care and transport infrastructure altogether. Source: Isaac Ribeiro.

The will of the people drove these measures forward in Brazil. In contrast, Pakistan was unable to pass a 2013 Reproductive Healthcare and Rights Bill through the Senate. 5 This Bill sought to enact policies and programs promoting reproductive health and associated rights in order to reduce maternal mortality and morbidity, as well as prenatal mortality.5 The bill also aimed to promote the right to reproductive healthcare information.5 It is alarming that the democratic process failed to uphold basic reproductive health rights of the people whom the process ought to serve. This failure begs a question about the behavior of the Pakistani people, after the state refused to even recognize such essential rights in 2013: where is the action? Naheed Aziz, a civil society activist, noted, “civil society should try to resubmit the bill with amendments, because only that is how the issues of maternal and neonatal health can be addressed.”5 Though the failure of the bill to pass through the Senate can be seen as democracy in action (and Brazil has experienced such obstacles as well), such a setback should not prove insurmountable, especially when the rights in question are central to the very structure of society.2

In Brazil, the health reforms were introduced in a structured, timely manner. A central policy of the SUS was decentralization and the process of decentralization “involved complementary legislation, new rules, and administrative reform at all levels of government.”2 Health councils and intermanagerial committees were set up at the state and federal levels so that health decision-making would occur by consensus. Each level of government took on more responsibility for its clearly defined functions, and had a stake in the implementation of the reformed health policy.2 All of these changes shifted toward the narrative of health as a universal right.

Following the 18th Amendment to the Constitution in 2010, the Pakistani government also pursued a policy of decentralization.3 The Federal Ministry of Health was abolished completely, and health became a provincial concern.3 According to a Lancet article, some improvement in health systems performance indicators occurred after decentralization, but Pakistan still lags behind its peer countries, and performs badly on key health indicators.3 Approximately 78% of the population pays for health expenses out of pocket, and 55% of the population lives on less than $2 a day.3 Even the very poor are forced to pay out of pocket, and “catastrophic health expenditure accounts for more than 70% of the economic shocks for poor households.”3 Though isolated attempts to ease this hardship have taken place, they are not part of a wider reform movement, but represent just another, problematic link in a series of jilted government programs designed to gain votes close to election years.

Eight years before the Prime Minister’s Health Program, the previous Pakistani government launched the Benazir Income Support Program (BISP), which provided a small amount of money (approximately USD 10) to female heads of “deserving” households. At the time, the program was lauded as an innovative approach toward extreme poverty, as BISP significantly increased the “amount of social welfare the Pakistani government was spending on the poor.”5 There were reports, however, that these funds were sequestered for political purposes. BISP began a pilot “Means for Health” program for the very poor comprised of group life insurance programs for the extremely underprivileged, with “basic income support measures to access health care and to cope with a variety of health shocks.”8 Research found, however, that the funds were misallocated for political ends, and even the money that reached poor families failed to serve its intended purpose: to help mothers and children cope with extreme hardship. Instead, reports commented that “most of the recipient women spent it on their male family members.”5

Though statistics on the implementation of PMHP have not yet been released, similar problems can be expected because the government failed to place substantial safeguards against corruption. According to the PMHP, when a cardholder is admitted to the hospital, a representative of the State Life Insurance Corporation will visit him or her. The ministry of National Health Services will supposedly enact separate mechanisms to ensure transparency, but the government has not released detailed plans for these safeguards.1 Considering the corruption of the existing bureaucracy, only extraordinary measures could prevent this program from falling prey to the politicized bureaucracy.

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Even the very poor are forced to pay out of pocket, leading to economic shocks for poor households. Source: UK DFID.

In Brazil, the implementation of the Family Health Program of the SUS enabled the system to evolve with time. Initially, the program “offered mainly maternal and child health services to more needy or at-risk populations,” and focused on “structuring municipal health systems.”2 Similarly, PMHP has worked toward modest aims. The government has negotiated charges for some basic health needs, such as USD 120 for the delivery of a child. PMHP has also listed the priority diseases that it will insure, including cancer, accidents, burns, diabetic complications, heart bypass, and infections.1 PMHP does not seek, however, to reform the system of implementation. The success of the Brazilian model depended upon the creation of a relationship between health centers and the local community, and the SUS placed “emphasis on the reorganization of primary clinics to focus on families and communities and integrate medical care with health promotion and public health actions.”2 This relationship was self-reinforcing, as both parties recognized the benefits associated with cooperating. PMHP, on the other hand, has no such features, and uses the preexisting system of one-way bureaucracy to implement its objectives. The bipartite- and tripartite-level committees and councils in the Brazilian model, in contrast, must reach decisions by consensus, ensuring that a greater level of cooperation and transparency exists even within the bureaucracy.2

Neither Brazil nor Pakistan has established a stable mechanism of securing funding for its healthcare programs. Brazil has struggled to raise enough taxes to fully fund the SUS. In fact, the percentage of health services paid for by public resources actually fell by 12% between 1981 and 2008.2 The problem lies in taxation effectiveness, an issue endemic to the largely informal economy of Pakistan, as well. Tax revenue represents only 11% of Pakistan’s GDP income and, without improvements in tax collection and a widening of the tax net, socialized healthcare in Pakistan will remain an unrealized dream.7

During his speech at the launch of PMHP, Prime Minister Sharif talked about a social mobilization campaign to make people aware of and enroll in his initiative.1 Instead of limiting the scope of this “mobilization” campaign to PMHP, the effort should initiate a nationwide struggle to make people conscious of their basic health rights. Perhaps it is counterintuitive to suggest that a government should remind its own citizens of their civic duty, but the people need to care about their own welfare as much as, if not more than, the state. Health is an intrinsic human right and should not be awarded on the benevolent whim of a leader. The people need to demand the healthcare that they wish to receive. Only when they urgently mobilize for universal healthcare will their government, or even the governments of many nations, feel compelled to make widespread policy changes. The basic principles of health reform in Pakistan need to change but, at least for now, the status quo will not allow that reform to occur.

Mahrukh Shahid is an international student from Pakistan and a junior in Morse College majoring in Molecular, Cellular & Developmental Biology. She can be contacted at mahrukh.shahid@yale.edu.

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References:

  1. Junaidi, I. (2016). PM launches health scheme for the poor. Dawn. Retrieved from http://www.dawn.com/news/1229970
  2. Paim, J., Travassos, C., Almeida, C., Bahia, L., & Macinko, J. The Brazilian health system: history, advances, and challenges. Lancet, 377(9779), 1778-1797.
  3. Nishtar, S., Boerma, T., Amjad, S., Alam, A. Y., Khalid, F., Haq, I. u., & Mirza, Y. A. Pakistan’s health system: performance and prospects after the 18th Constitutional Amendment. Lancet, 381(9884), 2193-2206.
  4. Monteiro C, Cavalcante T, Moura E, Claro R, Szwarcwald C. 2007. Population-based evidence of a strong decline in the prevalence of smokers in Brazil (1989–2003). Bulletin of the World Health Organization, 85, 527–534.
  5. Research shows BISP is ‘biased, misused’. (2014). Dawn. Retrieved from http://www.dawn.com/news/1112696
  6. Reproductive Healthcare and Rights Bill, S., 90th Cong. (2013).
  7. Tax revenue (% of GDP). (2014). Retrieved from http://data.worldbank.org/indicator/GC.TAX.TOTL.GD.ZS
  8. Benazir Income Support Program. (n.d.). Retrieved from http://www.bisp.gov.pk
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