Pakistan is a country that values the tangible over the ephemeral. We are a nation that treasures sensationalism over silence; swagger over humility; and the immediate over the lasting. We celebrate Afridi’s boisterous sixer, over six crafty singles of Misbah. We glorify whimsical suo motos of Iftikhar Chaudhary over the structured need for judicial reform. We idealise the pomp of Long Marches and dharnas over the voiceless humdrum of legislative progress. And in the same breath, we rally behind physical monuments of political progress, above and beyond the quiet rhythm of permanent revolutions.
As a part of this ethos, our political machinery seems to have chosen to surrender silent issues, such as ‘public health’, at the altar of flamboyant projects such Metro Bus, Signal-Free Corridors, and the Orange-Line.
According to a recent report published by the World Health Organization, Pakistan ranks 122 (globally) in terms of the quality and reach of its healthcare systems; much behind even some of the far less developed countries such as Lithuania (73), Libya (87), Fiji (96), Iraq (103), and Tongo (116). There are hundreds of ghost-hospitals all across our land. The best and the brightest of our doctors continue to seek more lucrative career opportunities abroad. Thousands of patients wait in the hallways of public healthcare facilities, dying a little with each breath. And recurring menace of drug/medication shortage continues to add to the plight of our people.
Only last year our media reported the heart-wrenching stories of, Isra Ghazal, a seven years old girl from Rawat who had bee diagnosed with leukemia, and Ayesha, a twenty-three year old patient of thalassemia, who could not be provided the requisite treatment, owing to non-availability of the affordable medication. These and other stories, across Pakistan, continue to exist as an indelible scar on our collective conscience.
As it turns out, according to figures provided by the World Health Organization, the Government of Pakistan spends only 1.5 per cent of its GDP on ‘Public Health’ (as opposed to almost 6 per cent spent by most other developing countries). In fact, the private sector, which is considerably more expensive (and thus beyond the financial reach of majority of Pakistan’s population), spends at least three times as much on providing health-related services within the country. A recent report published in the Journal of the College of Physicians and Surgeons, Pakistan, details how Pakistan spends 80 per cent of its health budget on tertiary care services, utilized by only 15 per cent of the population, and 15 per cent on primary healthcare services, used by 80 per cent of the population. Furthermore, 98 per cent of all healthcare related expenditure, in Pakistan, are done out-of-pocket, and over 75 per cent of patients visit and use private-sector healthcare facilities. The total public health budget of Pakistan dwarves in comparison to the budget allocated for the top three infrastructure projects, and the government healthcare facilities receive a smaller fraction of the overall budget, than the subsidy provided to the airline-sector alone.
This deprecation of our public health is not simply the result of inadequate funds. The deeper issue stem from a constitutional disregard of the sector.
From the constitutional perspective, per Article 70(4) read with Article 142, the Federal Legislature has exclusive legislative authority in regards to items specifically enumerated in the Federal Legislative List (Fourth Schedule of the Constitution). As a result, only the Federal Government has the authority to constitute ministries and sectors that are expressly mentioned in the Federal Legislative List, and all other items (post 18th Constitutional Amendment) fall within the exclusive legislative domain of the respective Provincial Assemblies (Article 142 (c)). And, admittedly, “Public Health” finds no mention in the Federal Legislative list at all, making it a ‘Provincial’ subject.
This constitutional paradigm, in which public health is exclusively a provincial subject, can also be traced through the earlier constitutional schemes of Pakistan, including the 1956 Constitution, and the 1962 Constitution. Still, however, throughout our history, there has continued to exist a Federal Ministry of Health (presently the Ministry of National Health Services (Regulation and Coordination)), and the Provinces have taken no meaningful steps to assert their respective autonomy over the subject.
Existing somewhere between this confused legislative domain, of a Federal healthcare apparatus vis-a-vis competing Provincial autonomy, our national focus on public health has suffered at the hands of debilitating apathy. Pakistan, having signed and ratified over a dozen public health related conventions and treaties, continues to lag behind the modern world in terms of provision of healthcare to its citizenry. We continue to host numerous diseases (e.g.: Polio) that have been eradicated from most other countries of the world. Our population growth is disproportionate with our healthcare budget. Our public sector doctors continue to seek better opportunities abroad. Our borders continue to stay porous for smuggled (expensive) medication. And caught in this myriad of public health problems, the people of Pakistan struggle to find their rightful place in the comity of healthy nations.
Faced with this sad state of affairs, the void in our public healthcare space is being filled (in part) by angelic private citizens of miraculous abilities; individuals who have no legal or constitutional obligation to participate in the public healthcare space, but have accomplished miracles through the dint of their hard work and moral commitment. This includes, above all, the late Abdul Sattar Edhi, and SIUT’s Dr. Adeebul Hassan Rizvi.
Why do State institutions exhibit such blind spots when it comes to public health ? Why is it not front and center in each political party’s manifesto and agenda? Why does the silent suffering of the sick find no space in the political and national narrative?
A healthy man, woman, or child, does not make for a great campaign slogan, or form the crown-jewel of political achievement. It cannot be advertised, like the Metro Bus, on placards and holdings. Public health does not manifest itself as a monument that beckons an opening ceremony from the Chief Minister. It cannot be displayed, as a mark of development, to foreign dignitaries. It does not suit our conventional need for tangible progress. And so, naturally, it does not form a priority in the hackery of our political system.
The crisis of public health , across Pakistan, is likely to continue till such time that we, as a country, shift our political preferences away from tangible monuments of stone and towards the intangible monuments of well-being. And if our political elites are not willing to do so, it is incumbent upon us, as responsible citizens of the State, to force their hand through the autonomy of our vote.
The writer is a lawyer based in Lahore. He has a Masters in Constitutional Law from Harvard Law School.