M. AFZAL NAJEEB There are almost as many healthcare delivery systems as there are countries. The roles of public and private sectors are variable and complex and an ideal mix of these is an elusive goal. Apart from the Scandinavian Welfare States no other country has been able to sustain a system based on total provision by the public sector. The British National Health Service falling short of capital spending had to seek sustenance from Private Finance Initiative and establishment of independent public benefit organisations viz the NHS Foundation Trusts. USA which spends the highest percentage of its GDP on healthcare still has major reliance on private sector for financing, purchasing and delivery of its health services and the Obama regime is grappling with a new bill to contain government spending on healthcare. Pakistan alongwith the other low income countries inherited a system of sorts in which the major portion of primary healt-hcare was purchased out-of-pocket from modern and traditional medical practitioners, while secondary and tertiary care were mainly provided by public hospitals. The growth in the public sector over the decades was not able to keep pace with the demands of demographic transition in the wake of population explosion, urbanisation, socio-cultural and economic changes. The government thereby started renouncing its responsibility in favour of private enterprise with the theme song of public-private partnership. So the private sector is now providing most of the secondary and tertiary care. This was inevitable, but the unfortunate part is that the delivery system in both sectors has never been planned nor regulated properly due to lack of a comprehensive and sustainable National Health Policy (NHP). Innumerable seminars, commissions task forces and advisory boards were set-up with the participation of local and foreign experts but their recommendations adorn the archives of the Ministry of Health. Each NHP could only be partially implemented because it was soon supplanted by a new one by the next regime. Adhocism has been the rule for most of the time at the whims of the politicians, military rulers and hierarchical bureaucracies, alongwith the mismanagement and corruption inherent in such an arrangement. It is indeed a part of the lack of direction, political will and institutional collapse in every sphere of our national life. Ironically, the separate health policy planning exercises going on in the federal and provincial capitals are still based on the concurrent list of subjects which should have been abolished decades ago. The present federal government has been engaged in carving out a NHP of its own and was able to produce a draft after more than one and half year. It is indeed an amazing document which is full of pledges, promises and platitudes about vision, goals and policy objectives. It states that the national and provincial authorities will plan and forecast human resource requirement, establish a national information system for collection of database, an integrated disease surveillance system will be initiated, and medical curricula will be locally contextualised and modernised. Surveys to develop deeper insight into private sector will be carried out leading to the creation of a model for regulation in the Islamabad Capital Territory which could then be replicated by the provincial authorities. A separate establishment is envisioned to undertake this function. It is a list of will-dos or at best a memorandum of intent. However, fails to lay down any concrete proposals on implementation strategies. Then the Punjab Health Department in its turn has been deliberating for the last two years over a Healthcare Bill (2009). Its draft became so controversial that it has been deferred and sent back to the Task Force for reconsideration. The six point agenda consists of same old clichs. It reiterates the intertwining complex relationship of factors like poverty, population explosion, illiteracy, lack of clean drinking water, malnutrition and environmental pollution in the health of nation. But the underlying motive in the package seems to be disinvestment of even the meagre 30 percent that the government is spending on health at present. It envisages to absolve the provincial government of the responsibility of primary healthcare by putting it in the lap of the federal government. The bill has identified the issues and problem areas correctly. However, as usual more surveys for data generation have yet to be carried out, and pilot projects and establishment of cells and authorities in different fields is still in the planning stage. Some of the proposed solutions are a replica of old schemes which had failed because of flawed implementation strategies. Furthermore, the Sindh Public and Private Hospital and Clinic Accreditation, Registration and License Act 2010 apparently is a well intentioned document but its true picture will emerge only after debate in the Provincial Assembly. Introduction of a Health Insurance Scheme is also being reconsidered. NWFP and Balochistan have yet to declare their policy statements. The hope expressed in the 10th Five Year Plan 2010-2015 that the allocation for health and education will be enhanced from 2.5 percent to 7 percent of GDP may actually be a far distant dream. All of these are efforts in futility like others in the past. It must be realised that only radical and fundamental structural reforms can bring about any worthwhile change in the delivery of healthcare to the masses. To begin with, the government must own the primordial principle that healt-hcare is a basic human right and its provision is the responsibility of the state, as enunciated in the words of a former Director General of WHO: The ultimate responsibility of the overall performance of the countrys health system lies with the government which in turn should involve all sectors of society in its stewardship. The health of the people is a national priority. Regulation again is a responsibility of the state since the private sector comprises of many different players and the national policy needs to carefully distinguish where to restrict and where to promote. The role of the leadership should be stewardship which means good governance, pragmatism and accountability to ensure cost containment and efficiency in the public sector and control of quality and profit margins in the private sector. The writer is a retired lieutenant general and professor of cardiology.