GIVEN the fundamental changes promised by the Punjab Health Ordinance, passed in great hurry in Jan 2002, the absence of any consultative process in its making is strange. It is important to initiate a debate to understand the various changes it envisages, and examine the repercussions of the establishment of Boards of Governors (BoG) in teaching hospitals in Punjab.

The preamble of the ordinance states the following objectives for passing this ordinance: “... to provide quality and affordable health care with special dispensation for the poor and vulnerable sections of society and for enhancing the quality of education in health sciences”.

Let us take the issue of affordability first. The immediate effect of the implementation of the provision in teaching hospitals has been the levying of user charges for various investigations — x-rays, blood tests, etc. Tests that used to be free at one point now cost Rs. 50-60 each. Registration fees have similarly risen from two rupees to Rs.10-20.

A quick round of Ganga Ram Hospital maternity ward showed that patients had spent around Rs. 2,000-2,500 for a normal delivery and approximately Rs. 5,000 for a cesarean section, including medication costs. This for giving birth, which is not a disease and does not normally require prolonged hospital stay or complex procedures. Ganga Ram Hospital has also imposed Rs.100 charge for a birth certificate without which the mother will not be discharged. Infant and maternal mortality is bound to increase as more people begin to avoid seeking professional medical care for deliveries for reasons of cost.

These charges may not seem much to the well-to-do. However, we must see it all in context. Until the ‘80s hospitals like Mayo Hospital provided medication, meals, clinical care, beds and clothing for patients. In fact, poor patients also received fare to go back home. Now, a patient entering any hospital, private or public, has to provide for his/her own medication, blood, etc. Medication of course is the most expensive part.

After the changes in the ‘80s, the only service that the government provided free of cost to the patients until January 2002 was the consultation of doctors and the investigative procedures for indoor patients. Within six months of the implementation of the ordinance in these hospitals, investigative procedures now bear a “user fee”.

Public health care is not a matter of charity or benevolence but of building and maintaining the working capability of the people in an organization or a country. Effective management of human resource for productive use requires that some basic needs are taken care of and people don not have to waste energy and time trying to get these individually. This is why the armed forces, for instance, have well-developed health and educational infrastructures of their own.

Similarly, the developed nations, especially in Western Europe, where the level of productivity is very high have realized this. In fact, it is interesting to note that France, which has many more holidays and shorter working days than the US, has a much higher productivity per person. France also has one of the world’s best public health-care systems. Without a good public health-care system Pakistan cannot make much progress in terms of material advancement.

Even worse, it might be argued that in a way the privatization of health and education produces a system that engenders corruption in our society. If one’s child is ill and one has to pay Rs.5,000 for his/her medication, or if the only chance he/she has of getting a decent education is for you to pay Rs. 2,000 a month in fees, then how else does one bear this cost out of a monthly salary of, say, Rs 2201 (based on the official figures for per capita income) except by resorting to unfair means to increase one’ income?

The ordinance also proclaims that ‘quality’ health care will be provided to the masses. This can hardly be possible when all the doctors and nurses seem enormously frustrated with the changes the new dispensation is bringing in. Their frustration is understandable. The formation of BoGs denies the achievement of years of hard work by doctors in setting up a service structure for themselves.

By the authority vested in the BoGs, they can hire or fire as they wish which is a negation of the terms of employment stipulated in the service structure for doctors. More important, there have been no public service commission exams in Punjab since 1995 and hence all the new doctors working in the public sector are effectively working on a contractual basis.

The new ordinance further demoralizes doctors by giving the Boards authority to fire without stating the cause. Even the Principal Executive Officer “shall be appointed for a period of five years but the Board of Governors may remove him before expiry of his tenure, without assigning any reason”. The termination of Dr. Mehmood Ali Malik as the chairman of BoG for Ganga Ram Hospital is a case in point. Dr. Malik, a former Professor and Principal of Kind Edward Medical College, Principal of Allama Iqbal Medical College and one of Pakistan’s most renowned physicians, was appointed chairman of the BoG for Ganga Ram Hospital. In his now famous address, he dared to criticize the faulty formation of the BoGs and their implications for patient welfare and quality of health care and health education. He was promptly removed from his post and to this day has not received any official notification detailing reasons for his removal.

Doctors are being told that their pay will rise ultimately and there will be no need for them to have private practice. In fact, the ordinance is being promoted as a step that will rid our society of the menace of private practice. Of course this touches a responsive chord among the people who pay heavy private consultation fees. However, private practice does fill a vital gap in the health sector and should be allowed within defined parameters.

While pay raises for new doctors have been announced in some hospitals, they have not yet materialized. In the spirit of market-oriented policies, we are told that the top tier of the hospital management must be paid corporate rates to attract talent. If we try to calculate the cost of the top four executives, the Principal Executive Officer (PEO), Deputy Dean, Medical Superintendent (MS) and Finance Director we see that just covering that cost is beyond the means of our hospitals and drains their resources to the extent that no other investment is possible.

Before the introduction of the pay scale for the top four, teaching hospitals spent around 80 per cent of their budget on establishment — salaries, building maintenance, etc., and 20 per cent on the day-to-day care of patients. With high salaries, parks and so on for the top four functionaries under the new dispensation, not much will be left for meeting the vital needs of a hospital.

As a result of all this, many well trained doctors in our hospitals today are ready to leave and look for opportunities in foreign countries. These are the people who could have taught the next generation, in addition to providing professional care for patients. The quality of health care and health education is bound to suffer as experienced doctors leave the public sector and new doctors have no incentive to remain in Pakistan.

It would however, be naive to assume that this ordinance is a well meaning but its implementation is flawed. There has been considerable criticism of the ordinance focusing on its implementation and perhaps not so much on the spirit of it. The implementation-oriented criticism has focused on issues like the way the BoGs have been hand-picked by the government, and the way rules laid down in the ordinance regarding selection of PEOs/members of board have been ignored to select either the most pliable doctors or the most influential industrialists.

In the final analysis, these details should be looked at against the backdrop of the wider picture. The fact of the matter is that Pakistan, like many other developing countries, is under pressure to declare to the WTO in March 2003 whether its health and education sectors are open to foreign investment or not. In fact, haste with which both the Health Ordinance and the Model University Act have been passed, make it clear that the health and education sectors are being prepared for further privatization. Thus, while claiming to stamp out private practice, the government is actually paving the way for making the whole health sector private.

The system in place before the bureaucratic meddling of Zia’s regime started was in fact very workable. Under it, the principal of a medical college was also in charge of the teaching hospital and was assisted by two different committees in his task of management. This allowed a unified approach and an accountability system under which the principal was clearly responsible for problems in either. In the 1980s this was changed to allow the health secretary a greater role in managing the hospital, especially its finances. This allowed a person who is not directly responsible to either patients or doctors to make important decisions. The 1980s incidentally was also the time that our policy-making came under the increasing influence of the World Bank and the IMF.

There is a need here to think independently regarding our problems and break free of the ‘solutions’ being imposed on us by international agencies advancing the cause of market economy and privatization in a dogmatic manner. Their nostrums are unsuited to our conditions and our stage of development. In our country public sector has yet to play a major role particularly in health and education.

A VISIT to Moscow by President Musharraf has been due since last June, when he had met President Putin during the conference on interaction and confidence-building measures in Asia in Almaty, Kazakhstan. It may be recalled that following his summit meeting with President Bush in May, 2002, at St. Petersburg, President Putin had taken the initiative to promote a dialogue between India and Pakistan, at a time when the forces of the two countries were confronting each other along the two countries’ common border.

This had taken place as a result of India’s decision to pressure Pakistan following a terrorist attack on the Indian parliament on December 13, 2001, for which it had blamed Pakistan. Though Prime Minister Vajpayee met President Putin then, he refused to meet the Pakistan president.

President Putin’s move to help reduce tensions between India and Pakistan was reminiscent of the role the Soviet Union had played in 1966 at Tashkent. As a Eurasian power, the bulk of whose territory lies in Asia, Russia has always aspired to play an active role in Asian affairs. Putin had embarked on the move to end the confrontation between the two South Asian neighbours with the encouragement of President Bush who was present in Russia at that time.

Since June 2002, Russia has made significant progress in internal consolidation as in its international role. A paradigm change in relations between the US and Russia, which were political and ideological rivals during the cold war, had taken place after President Putin expressed solidarity with President Bush’s war against terrorism after the 9/11 attacks on the US. Putin, who was ahead of the US in blaming Islamic fundamentalism Particularly with reference to the alleged of Muslim militants in the rebellion in Chechnya, took full advantage of the convergence of perceptions on this threat with the US. Russia fully supported the operations against the Taliban and Al Qaeda in Afghanistan, and encouraged the Central Asian states to provide military facilities to the US.

However, as a partner in the war against terrorism Russia was a relatively minor player, compared to the behemoth it seemed during the cold war years. What contributed to the steep decline in Russia’s global standing was its political disarray in which the economic meltdown that followed the shift from a command economy to a market-based one was a major factor. After years of mismanagement and exploitation by the oligarchs, Russia’s GDP fell to that of a small European state like the Netherlands by the end of the 20th century.

Putin was chosen as successor by President Yeltsin, whose decade in power constituted a sorry record of decline and decay. The once mighty superpower suffered military setbacks at the hands of tiny Chechnya, as its economic predicament brought the large mass of its people down to Third World levels of subsistence. As its economy went into a tailspin, it became heavily dependent on the western countries for financial support. As his health declined, Yeltsin saw in Putin, who had been a relatively obscure official in the KGB, the makings of a leader who might rescue Russia from chaos and decline. One of the major factors in his choice was the tough stance he, as prime minister, had taken against the Chechen rebellion, where he deployed the full might of Russia’s still considerable military power.

The three years during which he has held power have witnessed major advances, both in political stability and in economic recovery. Putin has been fortunate in that the price of oil, which is a major Russian export, has risen steeply, bringing about a significant improvement in the country’s balance of payments. The administrative and economic reforms have achieved some results, though not as remarkable as those claimed by the government.

According to an assessment in the US magazine, Foreign Affairs, though the parliament has been tamed through the decisive defeat of the communists, the administrative reforms are not really working. The seven large prefectures created out of the country’s 89 regions find themselves facing resistance from federal ministers or local governors. The hold of the oligarchs is still strong, and that of big business growing. The top ten companies which accounted for 57 per cent of profits in 1997, increased their share to 61 per cent in 2000. The number of small enterprises fell by 48,000 in the first two years under Putin. Corruption is rampant, and the crime rate has gone up. The most dramatic change has been in the distribution of tax revenues, accompanied by lower taxes. The important fact bolstering Putin’s power is that his popularity, originally based on his toughness towards Chechnya, remains high.

Putin appears to have achieved his greatest success in the domain of which has yielded both economic and political dividends. He has virtually completed the transition from the confrontationist tradition of the communist regime to a strategic convergence with the United States. Under him, Russia has been drawn into Nato’s orbit, and following its inclusion in the Partnership for Peace, Moscow has been accorded a special status through the Nato-Russia council that was created recently. Though a very close linkage had existed between Russia and Saddam Hussein’s Iraq, Putin has lowered support for it.

Hitherto, public opinion in Russia was very sensitive about the relegation of the country to a secondary status after the end of the cold war. However, a certain pragmatism has emerged among the ruling elite, and the popular acceptance of the pre-eminence US as the sole superpower has widened. This has been a natural response to the US acceptance of the traditional role of Russia as the paramount power in Chechnya, and other formerly colonized areas that remain within the Russian Federation.

President George W. Bush has realized the advantages likely to flow from a cordial equation with Moscow which has to depend on economic and technical assistance from the West. However, he has not abandoned his unilateralist stance but has only sugarcoated it by accommodating Russia’s economic and political requirements.

In Asia, Russia banks heavily on its relations with the two largest countries, namely India and China. The relationship with India is of long standing and it flourished even relations with China were adversarial. Despite the end of the cold war, and the readiness displayed initially for more balanced relations with the South Asian states, the convergence of interests and perceptions with India has prevailed. Pakistan, which was in the opposite camp during the cold war, also became identified with forces considered hostile after the end of the cold war. Islamabad’s role in the rise of the Taliban and the popular backing to the freedom struggle in Chechnya, revived memories of Pakistan’s major role in backing the Mujahideen against the Soviet occupation in Afghanistan.

Since Pakistan’s assumption of a key role in the war on terrorism, and its contribution to the ouster of the Taliban, obstacles to normal relations disappeared. President Putin, while giving primacy to reviving the many-sided cooperation with India, did take the initiative last year to promote a dialogue between India and Pakistan. He has publicly praised the role of President Musharraf in the war against terrorism, though he also echoed the concern voiced in the US about the security of Pakistan’s nuclear assets. Taking into account Russia’s geographical position as a Eurasian power, its historical links, and influence in Central Asia, and its status as a permanent member of the Security Council, it makes eminent sense for Pakistan wanting to develop cordial relations with Moscow.

President Musharraf’s visit will provide an opportunity for both sides to further their own national interests, as also to address shared concerns for peace and security in the region. The Indo-Russian entente is a fact of life, and President Putin’s influence in New Delhi can be an asset in furthering the cause of dialogue. There has been concern in Pakistan about Russia’s agreement to sell sophisticated weapons worth three billion dollars to India. The coming visit will enable President Musharraf to brief the Russian leader on the risks associated with an excessive Indian arms build-up, especially with reference to New Delhi’s disregard for its responsibility in maintaining a peaceful environment in the region.

Mr. Putin is expected to appreciate Pakistan’s perseverance in seeking a negotiated settlement of its political differences with India. This contrasts with India’s threats to unleash war on the basis of its accusations of “cross-border terrorism”, and its persistence in a confrontationist stance, while rejecting Pakistan’s efforts for resolving disputes peacefully.

The coming visit will facilitate closer relations, notably in the economic and cultural fields. Some agreements are being readied for signing during the visit, and President Putin will be invited to return the visit, so that a continuity of top-level contacts is ensured. This is essential in view of Russia’s growing role in world and Asian regional affairs and Pakistan’s interest in seeking a peaceful resolution of the problems straining its relations with India.

POLITICS in Bangladesh is still petty and personal. For the last 20 years, it has revolved around the two ladies: Begum Khaleda Zia, head of the Bangladesh Nationalist Party (BNP), and Shaikh Hasina, head of the Awami League. There is no love lost between the two and they make no secret about it.

The last time when I was in Dhaka, a little more than a year ago, Khaleda Zia, by then prime minister, was in the midst of removing from government offices and public places the photo of Shaikh Mujibur Rahman, founder of Bangladesh. What is held against him is that he is the father of Shaikh Hasina. This time Khaleda was busy apportioning the blame to Hasina for America’s decision to list Bangladesh among terrorist-risk countries.

Both instances show the extent to which Khaleda can go to hit out at her opponent. But Hasina was no better when she was in power one and a half years ago. She too went out of her way to rub Khaleda and her party the wrong way. Unfortunately, the country is a hostage to the two ladies who would rather settle their personal scores than do something tangible for the nation of 130 million people.

Once when the two joined hands, they were able to retrieve the country from military rule under General Ershad. Together they could probably pull the country out of the quagmire of poverty and unemployment in which it is stuck. But there is no such likelihood. Nor is there any escape from them.

The fact is that the nation is evenly divided between the two. One’s action is the other’s reaction. The BNP got more seats in the last election while the Awami League polled more votes. The civil service is split in the same way, some loyal to Khaleda and some to Hasina. Still it is not fair to treat the two parties at par. The BNP is a creature of General Ziaur Rahman, Khaleda’s deceased husband, who came to power through a military coup. The Awami League was the instrument that Shaikh Mujib used to free East Pakistan from the clutches of West Pakistan. Their quarrel torments the country even after 32 years of its liberation.

The BNP is pro-army. Only a few days ago Khaleda utilized its services to curb the criminals who had become a menace. (West Bengal is suspected of giving them shelter). The army has gone back to the barracks but the Khaleda government has seen to it through an ordinance of indemnity that the army is not punished for its acts of omission and commission. Some 44 people reportedly died in the army custody.

Indeed, the ordinance has created a furore in the country. The editor of a popular Dhaka English daily has written in a front-page commentary that the ordinance should be in the Guinness Book of Records because such a step had never been taken in any part of the world. Khaleda’s reply in a speech was that the country should be aware of “press terrorism.” Even otherwise, she has begun exerting pressure on the press which has been free so far.

Like rulers in other countries of the subcontinent, Khaleda is particularly incensed over the press criticism of the extra-constitutional authority her son, Tariq Zia, enjoys. He reportedly throws his weight about and has a group called, Hawa Mahal. He has inducted into the group young ministers and young leaders of the party. They have an unsavoury reputation of being the real rulers. They have come to acquire a lot of power for being near to the throne.

A large number of fundamentalists, who drown the voice of liberals, are the backbone of the BNP. The Jamaat-i-Islami is its ally in the government with two berths in the cabinet. Social welfare or whatever it connotes is one of the Jamaat’s portfolios. Whether it is because of its influence or the growing impression in Bangladesh that Islam is under siege, more and more people are congregating for prayers on Friday. “I have never seen so many young people at the Juma namaz,” a leading businessman of Dhaka told me.

Still, the anti-America feeling, which emanates from the belief that Washington is out to fight against Islam, is “controlled” in Bangladesh. There are very few demonstrations in support of Iraq. But there is a fair amount of unease. In Pakistan, which I visited three weeks earlier, the tension against the US is so thick in the atmosphere that I could almost taste it. In comparison, Bangladesh is mild, if not tepid. One possible reason could be that the country’s economy, which is not in good shape, is too dependent on the “donors” led by America.

The Awami League is on the same wavelength when it comes to the US. But it is not enamoured of the army although Hasina was the one who increased the pays and perks of the armed forces. She makes it a point in every conversation that Khaleda all along has lived in a bungalow in the cantonment suggesting that she is part of the “establishment,” which includes the army.

From India’s point of view, the Awami League’s plus point is that it jells with New Delhi better than the BNP. Shaikh Mujib’s independence struggle was helped by India. Hasina is conscious of that. Before she became prime minister, there was not a single monument to commemorate the memory of the Indian soldiers who died during the Bangladesh war. Khaleda tends to tilt towards Islamabad. “This is a wrong charge against us,” says Foreign Minister Morshed Khan.

He also denies the presence of the ISI and training camps for terrorists in Bangladesh. “You can come with your team whenever you like without notice and go around the country to see if there are any training camps,” he says. “We shall give you helicopters.” Regarding the ISI, Morshed Khan said: “It is as much present at Dhaka as in New Delhi.” Still there is no running away from the fact that both the ISI and the training camps exist in Bangladesh. But they were there even during Hasina’s regime. The only difference is that the number has increased under the Khaleda government.

The businessmen and industrialists of Bangladesh do not like anything which creates distance with India. They want more and more trade, which has already touched a figure of three million dollars. They welcome Foreign Minister Yashwant Sinha’s proposal to develop Saarc into an economic unit. “Our destiny is linked with India,” says Law Minister Moudud Ahmed. “We have nothing to do with Pakistan which is a failed state.” He believes that the sale of gas will not come in the way. His colleague Morshed goes further: “We have decided to sell you gas.”

People too have no objection provided it means the development of their country as well. “Why not joint projects?” some influential businessmen ask. New Delhi is still stuck on the number of commodities to be allowed to come in from Bangladesh without duty. I think whatever that country can produce should be duty-free. This is in our own interests. Such a step will create jobs and the Bangladeshis do not have to infiltrate into India. The problem is economic, not political. New Delhi should have realized this by now.

The writer is a leading Indian columnist based in New Delhi.