State and Citizens | Malik Muhammad Ashraf

The responsibilities that the state needs to fulfill

Providing health care and education are universally recognised as essential and basic responsibilities of the state towards its citizens. The constitutions of most of the countries also recognise them as basic rights of the citizens, making it obligatory on the state to ensure adequate facilities for its citizens in these areas — of course, within the available resources. The Constitution of Pakistan under Article 25 A also recognises free and compulsory education for the children from 5 to 16 years of age as a fundamental right, whereas Article 38(d) under Principles of Policy stipulates: “The state shall provide basic necessities of life, such as food, clothing, housing, education and medical relief for all such citizens, irrespective of sex, caste, creed or race, as are permanently or temporarily unable to earn their livelihood on account of infirmity, sickness or unemployment”.

Since the domain of the current discourse basically pertains to health cover and medical facilities, I would like to focus on the meaning of the Article 38 (d). Before venturing to unravel the state of health care in Pakistan it would perhaps be pertinent to point out that all over the world the states recognise and are engaged in ensuring cheap and unfettered access to health facilities by its citizens either through free medical treatment in government health units or through health insurance schemes suiting their own environment and the availability of resources. Health invariably is the top priority of the governments in view of its pivotal role in promoting social and economic well-being of the people.

Unfortunately in terms of comparison in regards to percentage of GDP spent on health, Pakistan is amongst the lowest in the world. In the developed world the percentage of GDP spent on health care ranges between 10-17.9 percent. Pakistan is spending 2.2 percent of its GDP on health care which is far less than what the regional countries spend for the health of their citizens. For example China, Afghanistan, India, Sri Lanka and Iran spend 5.1 percent, 7.6 percent, 4.1 percent, 2.9 percent and 5.6 percent respectively of their GDPs on health care. This testifies to the most sordid reality that since independence health care has invariably remained a low priority of all the successive governments which adequately explains our inability to keep pace with the other developing countries who attained independence just about the same time as we did.

Whatever facilities have been created in the public sector are poorly managed and the standard of health care is abysmally low .This sector is also afflicted with all permeating corruption with the result that the people are forced to depend on private hospitals and private medical practitioners who have mushroomed during the last two decades and are fleecing the public at will without any check on their machinations. The result is that medical health care is fast becoming out of the reach of the common man, particularly the poorer sections of the society and those living in the far flung areas of the country. Going to a private hospital even for minor sickness costs around Rs2,000-3,000 due to the reason that the doctors sitting their charge exorbitant consultation fees and invariably prescribe two to three tests which are either done within the same hospital or sometime referred to other laboratories with whom they have an arrangement to share the booty. A normal delivery case costs around Rs70,000 if one is lucky to survive an easy option for the concerned doctors to perform Caesarean which could swell up to Rs100,000.

It is indeed a very pathetic situation, for the poorer sections of the society, the under-privileged and those living below the poverty line. However, it is heartening to note that at last some tangible steps are being taken to provide health care to these sections of the society as envisaged under article 38(d). The National Health Insurance Scheme announced by the Prime Minister for the poorest of the poor during the last budget has finally become a reality. The scheme is the first of its kind purported to set up a system to address the grievances as well as a social safety net for the poor people of the country.

The scheme will not only give the vulnerable sections of the society an access to cash free health facilities but will also help to develop and revolutionise the health infrastructure across Pakistan besides promoting public-private partnership leading to further investments in the health sector. The scheme which initially has been launched in 23 districts across the country, four from each province and two each from AJK, Gilgit-Baltistan, FATA and one being the federal capital, will initially target 10 million people with daily income of less than Rs200 per day whose families will be provided free secondary and tertiary health care facilities. Under this scheme the families would be provided health insurance cover of Rs50,000 per family for secondary health annually and Rs250,000 for tertiary health respectively. The tertiary health insurance of Rs25o,000 will cover serious diseases like heart attack, diabetes, burn injuries, kidney treatment, excluding its transplant, and cancer.

The identification of the families will be done from the data compiled by BISP. The cost of the insurance scheme will be shared by the federal and provincial governments. While the provincial government would provide for secondary health insurance, the federal government would bear the expenses on tertiary health insurance. The scheme is likely to become operational by the end of 2015. It was initially envisaged to cover 100 million people at a cost of Rs45 billion but due to financial constraints and other pressing needs it has been curtailed to cover only ten million. It will, however, gradually be extended to the entire country depending on the outcome of the first phase of the pilot project.

The financial bids to execute the three-year targeted free health insurance scheme were opened on 16 September in the presence of all the stakeholders and the media after a thorough evaluation of the proposed scheme in the light of the criteria prescribed by Public Procurement Regulatory Authority, which was won by State Life Insurance on the basis of lowest bid, which incidentally was 50 percent less than the threshold envisaged by the government. The insurance company will soon start process of enrolment of the families, taking hospitals on the panel and providing health insurance services to the enrolled families.

The scheme as envisaged by the government on the face of it looks quite impressive, beyond reproach and a commendable step towards providing health care to the deprived and poorest of the poor segment of the society and above all a tangible effort to fulfill the constitutional obligation of the state. Its success will largely depend on follow up actions in regards to monitoring of the implementation process and ensuring transparency in the selection of the deserving families. The government, nonetheless, deserves appreciation for the initiative.

The government is also under obligation to provide affordable health cover to other segments of the society. When its talks about public-private partnership in regards to investment in the health sector, it must also make sure that the cost of health cover remains within the reach of the larger chunk of the population and the private hospitals are also properly regulated to plug the avenues of rip off.


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