By establishing the Prime Ministers National Health Programme, the PML-N government has taken a step into the world of socialised medicine, a step away from the present capitalist model. However, presently, this is merely a baby step, for the coverage is by no means universal, nor is it unlimited. However, it only covers certain life-threatening diseases: cardiovascular diseases, Diabetes Mellitus, Burma and RTA (life and limb saving treatment, implants, prosthesis), and cover end-stage renal diseases and dialysis, chronic infections (Hepatitis), organ failure (Hepatic, Renal, Cardiopulmonary) and cancer treatment (chemo, radio and surgery).

The basis of the scheme is an insurance premium paid by the government to State Life Insurance Corporation. The scheme is primarily a welfare measure, because it is not universal, with only poor people eligible. The Scheme is a sort of tacit admission that the Benazir Income Support Programme is, if not running aground, at least not delivering the desired results. Ideally, the BISP should help beneficiaries pull themselves out of poverty sufficiently to afford the kind of healthcare available in Pakistan, but it seems that it did not. The poor need more support.

Perhaps one of the most interesting challenges posed by the scheme is to the medical profession. It has developed in line with the governments previous policy, of being the main provider of healthcare, through its network of hospitals. The government back in the 19th century had to push two differing things: the allopathic system of medicine, and medical education. Medical education, especially after the first two years, was based on studying actual cases. This meant that the most easily available teachers were the consultants of wards. Not just in Pakistan, the consultants became teachers. The hospitals at which they worked became teaching hospitals. Ultimately, when consultants engaged in private practice, they used their hospital positions as sources of advertising. An ill person does not really care whether the person who cures him is a professor or consultant or even a doctor. He just wants relief. The teaching hospitals recruited, as far as possible, the best specialists, until a post at a teaching hospital meant medical excellence.

Then came the advent of private medical facilities. Such facilities as comfortable rooms and the availability of a large number of TV channels would only go so far. Patients needed the assurance of good consultants, so private hospitals found it in their interest to employ those who had consultancies at teaching hospitals. Many hospitals were set up in the private sector by medical teachers. Even for those who did not have their own hospitals, a teaching position meant a boost in private practice, both at their own clinics, as well as at private hospitals. It should be remembered that while the patient goes in danger of perhaps his life, the private practitioner is carrying out a business, whether the humble neighbourhood general practitioner, or a professor at a medical college. Because it is a business, the capitalist model has dominated.

The natural impulse for governments is to provide free medical care. This might have been possible when medicines came from plants, and doctors made up their own pills, but the advent of antibiotics meant that pharmaceutical companies had to spend huge amounts on research which had to be recovered in high prices of medicine. There was serious money to be made out of medicines, and thus medical research. This meant that researchers had to be attracted, by throwing money at them. Again, the ultimate payer was the consumer of the medicine.

Medical insurance was a tool developed to meet this. The idea of paying a small amount now, so that the insurer could pay for the treatment later. That is the principle applied in this scheme with the government paying the premium, so that expenses will be reimbursed by the insurer upto Rs 300,000, with the Baitul Mal to pick up any further expenses. That there will be further expenses will be an unfortunate inevitability.

The scheme is a tacit admission of the failure of the prevalent model, which in theory provides complete free medical treatment. One of the results is that the government has a vast network of medical facilities where this scheme will be applicable. It is not the sort of free medical care provided by the UKs National Health Service, under which part of the private sector was nationalized in 1948. It comes just after the USA got Obama Care. The UK has seen the NHS cost huge sums, as did the predecessor of Obama Care, Medicare. Apart from cost, there is the issue of coverage. The NHS was universal, though there was an option to engage doctors privately, which was an expensive proceeding. Medicare, on the other hand, was meant only for the poor, with the wealthy having to pay their way, or through some form of health coverage by their employer, or through health insurance. There is the problem with the present scheme that it is not accessible to the wealthy (who might not be very rich, but who still fall ill).

There is also the issue of whether the medical profession can handle the new scheme. It needs specialists in a certain number spread over the country. The present system has not delivered one, with specialists preferring to work in medical colleges in big cities rather than as specialists in smaller cities. The opening of medical colleges in cities other than the metropolitan centers addresses both the problem of medical college places as well as having consultants available in smaller towns. One problem with having specialists available is that they usually have children, and pay particular attention to their education. Thy prefer moving to a metropolis not just because it affords opportunities for private practice, but because it has better educational opportunities. The Danish Schools initiative is important in that respect, not so much for the opportunities afforded to the children of the poor, as for the raising of standards in the mofussil.

The initial responsibilities are the provision of justice (and maintaining law and order), keeping communications open, all the while keeping taxes low. Then education and healthcare have to be provided. In Pakistan, both systems have broken down, mainly because both are seen by politicians as sectors where jobs can be found for supporters. Healthcare is crucial. It is no coincidence that two of the three main political parties are led by people who have an involvement in healthcare (the Sharif brothers through the Sharif Medical City, Imran Khan through the Shaukat Khanum Hospitals). It is worth noting that the PPP is led by someone who entered through the traditional politics of inheritance and fiery rhetoric; Mian Nawaz entered with the medical activity going on but he was not prominent, while Imran actually made the SKMT cancer hospital an argument for politics. The PMs National Health Programme does not solve the countrys healthcare issues, but at least it acknowledges that a problem exists.

n The writer is a veteran journalist and founding member as well as executive editor of The Nation.