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, commission’s 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 clichés. 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 country’s 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.

SHIREEN M MAZARI

The terrorist attack in Lahore targeting a Special Investigative Unit has once again highlighted all the things wrong with our government and the state structures, especially when it comes to dealing with the terrorist problem. The plethora of statements, coming from various segments of the state in the immediate aftermath of the blast, shows the confusion that still prevails when it comes to the terrorist threats. There seems to be no proactive policy at the macro level to tackle the issue pre-emptively with good human intelligence and isolation of the militants and their supporters amongst the populace. After all, without local informants and local support, non-state actors cannot get shelter. In military terms, for the militants, a local sympathetic population forms their rear and it is here that they blend in to carry out their lethal activities.

So the first job of the intelligence set-ups and the government should be to ensure that the local population not only does not support the militants but also gives information about suspicious activities in their neighbourhoods. It does not seem possible that strangers simply drove into Model Town, found the target and carried out their terrorism. In urban residential areas, especially, it is easy for terrorists to blend in and watch their targets once they have been correctly identified. At the very least the government needs to encourage local watch groups so that suspicious people or strangers are identified and checked. These are abnormal times and require measures on an emergency footing. Television can aid in educating the public on how to arrange for local watch patrols and so on.

Equally important, it is absolutely necessary for the government to move interrogation and other high profile targets out of residential areas where innocent citizens lives can be placed in jeopardy. Locating such centres in the midst of schools and homes is showing scant regard for the lives of the citizens. Ironically, this was not the first time that an intelligence office located in Model Town was targeted; yet the government made no attempt to remove this interrogation set-up from this residential area. It stands to reason that militants would want to get rid of detained people who may reveal sensitive information. So all such interrogation centres are high value targets for them.

At a more general level, the state needs to be clear who are the groups they are fighting in terms of the terrorist threat. We seem to be particularly weak on this count. The Taliban have claimed responsibility for the latest Lahore attack but Rehman Malik and Punjab

MIRZA JAWAD BAIG

If, therefore, we sincerely desire to establish our local governments in accordance with the norms of a free democratic society, we shall have to have a united structure and move away from the present dichotomy. Functions such as those relating to the police, revenue and land administration, health, education, agriculture, administration of justice and all other local functions shall have to be handed over to the local governments as is usually practiced in free and democratic countries everywhere.

When the district level governments have been organised, the stage would be set for going a step further and strengthening the union councils in the rural areas. Similarly, in large and compact areas and metropolitan centres, zonal municipalities should be organised to ensure maximum participation of the people in the management of their affairs.
Apart from the federal government, the other two tiers, namely provincial and local administration, should have the corresponding functional role as under:
Level of Government
1.1 Provincial Government 1.1 Regional planning.
1.2 Coordination between local governments.
1.3 Execution and maintenance of region-wide projects mainly through sectoral authorities.
Functional Role
2.1 Local Government 2.1 Police
2.2 Revenue and general administration.
2.3 Special services i.e. health, education etc.
2.4 All other functions at present performed by provincial government other than listed at
1.1 to 1.3 above.
2.5 All present local government functions, other than those to be delegated to rural and urban councils.

The above distribution of functions is universally adopted by democratic societies all over the world and is based on

Some fabulously rich Pakistanis keep their wealth abroad. The masses condemn it as a horrific disloyalty to the motherland. The condemnation exposes the masses

The Lahore that was

Chauburji

It was a glorious spring day in 1960 that I accompanied my father to the Radio Pakistan Lahore for an audition. This was a time when the radio station was housed in a sprawling old bungalow near the Simla Pahari gate of the Governors House. The studios were located in the main building, while a

The other day, when asked to give a talk at the American University in Washington, DC on the issues surrounding Western-Muslim tensions, what was expected to be a 90-minute session got extended to three hours, largely because of the dimensions of the discussion and the lively participation of on-campus students. It offered some revealing glimpses.

The discussion centred on the motives behind militancy, existing policy failures, and the search for viable remedies to reduce polarisation.
During the concluding phase of the discussion, convergence was reached on key points. The students posited that the much-touted notion of the clash of civilisations was faulty in that it presupposed a perpetual conflict which, while suiting vested interests, was at variance with historic precedent, wherein Muslim culture traditionally had shown its capacity for pluralism and inter-religious coexistence.

It was also brought forth that Judaism, Christianity, along with Islam stemmed from the same region and the first two were by no means European products. Accordingly, the term