|
| November 12, 2006 | Sunday | Shawwal 19, 1427 |
Please Visit our Sponsor (Ads open in separate window)
Driven by rage
Bonded labour must go
Need for health insurance
God’s squads
IN Pakistan, public healthcare provision has not been successful in creating health security for the poor. The sector remains grossly under-funded, with public expenditure on health accounting for barely 0.5 per cent of the GDP of which close to 75 per cent is spent on salaries. There are only two countries in the world — Nigeria and Sudan — that spend less than this proportion on health.
THE Supreme Court is to be commended for taking a firm stand on an issue which is not simply a human rights problem but also has a profound human dimension. This is the phenomenon of ‘enforced disappearance’ that has emerged in recent years in Pakistan as a matter of serious concern. Generally this involves the disappearance of people picked up by the police and intelligence agencies who detain them without regard for legal procedures. In gross violation of the rules and by using their absolute powers, these agencies have been defying the judiciary which has intervened frequently under habeas corpus petitions filed by the families of the victims. The department/agency concerned has very often denied holding the detained person.
Take the case of the 41 missing persons whose case the Supreme Court has taken up on the application of the families concerned. Having been directed by the apex court to trace these people, the federal government reported after several weeks that nine of them had been found but failed to provide any details. The plea taken for its non-compliance with the court’s direction was frivolous and betrayed the government’s non-serious approach to such cases. The court was told by the deputy attorney-general that a comprehensive report had been prepared on the matter but could not be presented because of the non-availability of the interior secretary to sign the document. It is, therefore, encouraging that the chief justice has given Dec 1 as the deadline for the report to be submitted and has warned the government that this time no “excuse” will be accepted. One hopes that the ministry of interior, which is technically responsible in such cases, understands the agony of the families of the missing persons and informs them of their whereabouts.
It is also important that all the agencies operating under the interior ministry, the provincial home departments and the armed forces intelligence network understand that none of them can consider themselves to be above the law. The Constitution of Pakistan recognises the personal liberty of every citizen. If anyone is wanted for any reason — interrogation, security purposes, pre-empting violence — he can be picked up by authorised personnel only after observing the prescribed rules and procedures. It speaks of the total contempt for the law of the land on the part of the official agencies that have picked up hundreds of people under all kinds of pretexts — be it the blanket cover of the war on terror or the ongoing war against ‘miscreants’ in Balochistan. This cannot be condoned and the Supreme Court has done well to take note of it. In many cases the agencies have tried to evade the rules by setting up ‘private’ detention centres of which the courts would be unaware and so fall outside the purview of their inspection. It is time the government assumed full responsibility in the matter which is now recognised internationally as a human rights issue. The Working Group on Enforced and Involuntary Detention that operates under the UN Human Rights Council has been looking into cases that are well documented. The HRCP has also tried to help by investigating cases — it has verified 170 of them in the last two years — but obviously the most it can do is generate public pressure on the government to perform its duty. Ultimately it is the government that must take effective mea-sures to prevent enforced disappearances.
A WOMAN and her teenaged son were strangled in Lahore on Friday following a quarrel with collectors from a local cable service. The bone of contention, apparently, was the payment of monthly dues. The sum could have been no more than a few hundred rupees, or maybe a thousand or so if arrears were involved. For this failing and the hot words that were exchanged, two lives were extinguished in a moment of blind rage. Also in Lahore on Friday, a young man was shot dead by his cousins following a domestic dispute. The same day, a man was hacked to death with a hatchet near Naushero Feroze, while two men were gunned down in a laundry shop in Karachi. One man was targeted; the other, it seems, just happened to be in the way.
Almost every day, people are killed for petty cash and even pettier reasons. Extreme violence is now routine, so much so that news of murder fails to excite more than a passing remark. As a nation we have become desensitised and prone to brutal behaviour. The fragmented nature of Pakistani society, with its visible disconnect between segments, is partly to blame for this lack of empathy with others. Then there is the growing sense of despair and hopelessness that is diminishing the value of human life: when there is nothing at stake, there is nothing to lose. Much is rightly said and written about religious bigotry and barbaric medieval practices such as honour killing. The sad truth, though, is that intolerance now dominates mindsets at most levels of human interaction. Minor traffic accidents quickly degenerate into brawls and sometimes end in murder. Haggling in shops can turn into vicious slanging matches, rife with threats of violent retribution. Kids carelessly tossing a ball can lead to neighbours killing neighbours. Tempers, it seems, are perpetually on the boil, with people almost looking for an excuse to vent their frustration. Clearly, there is no shortage of aggravation — dismal pay for hard labour, abusive employers, cruel husbands, power outages, dirty water, uncollected garbage, mind-warping noise and air pollution. When walking or driving down the road, try counting the people who are smiling. Even on the most pleasant of days, the answer could be zero.
IN this day and age when workers’ rights are considered inviolable by civilised societies across the world, it is a matter of shame that Pakistan should be home to bonded labourers numbering in the millions. The distressing account of one bonded labourer and her family published in this newspaper the other day is, in fact, reflective of the fate of many others who for lack of money, education and influence remain in a state of virtual slavery. Not only are these labourers made to work long, back-breaking hours for two meals a day in order to pay off ever-mounting loans, many suffer physical and mental abuse, including rape and torture, at the hands of their cruel employers. The law, it seems, is powerless to restrain or punish landlords and others of their ilk whose medieval values as well as clout with the local police have left bonded labourers with no one to turn to for help. Few manage to escape the clutches of their employers and seek justice before a court of law. In this context, the Bonded Labour System (Abolition) Act 1992 can be deemed a disappointment for its failure to curb the excesses of the perpetrators of this form of servitude or to rescue labourers from the ‘peshgi’ system.
Why is this subject not being debated in parliament which would be the right forum to discuss the non-implementation of the law and the Constitution which bans forced labour? Besides our lawmakers, the relevant government department too needs to be activated so that labour inspectors regularly visit those parts of the country where bonded labour is practised. Meanwhile, setting up several loan and rehabilitation schemes for labourers will encourage the latter to stop borrowing from their employers and provide them with an opportunity to look for alternative and financially more rewarding means of livelihood.
It is around one per cent for India, two per cent for Bangladesh and Nepal and three per cent for China, while for most developed countries it ranges from five to seven per cent.
More than 80 per cent of the total healthcare expenditure is spent by the private sector and almost all of this represents private out-of-pocket expenditure on curative care — consultations and in-patient diagnostic care, laboratory tests and medicines. It is noteworthy that between 1990-2001, three countries — Bangladesh, Nepal and Bhutan — which recorded the maximum increase in public expenditure on health, also recorded the maximum reductions in infant mortality rates (IMR). The average annual reduction in IMR for Bangladesh was 7.6, Bhutan 4.7, Nepal 5.8, Sri Lanka 3.9, Pakistan 1.96 and India 3.1.
Moreover, even the benefits from these low levels of spending are spread unevenly between the relatively affluent and the more vulnerable segments of the population. Equity and quality considerations in healthcare have been vastly neglected and there are continuing disparities in health outcomes. There are glaring failures in the management and delivery of quality healthcare. The health sector has acquired a notorious reputation for inefficiency and corruption at all levels. Most of the government-operated outlets for primary healthcare, except perhaps in Punjab, are on the verge of total collapse.
Quality standards are practically non-existent as are performance assessments, with little accountability in both public and private sectors. Very few norms and standards are adhered to. The consequence has been the growth of a large private sector that, as economist Amartya Sen said in the case of India, thrives on “quackery and crookery”. There is little performance monitoring in health centres. A forward-looking and progressive vision has to be grounded in the principles of equity, rights, justice and respect for human dignity.
There are some forms of social welfare protection instruments in many countries like unemployment benefits or social security for the needy, driven by the belief that it is the primary responsibility of the state to look after its citizens. Free or subsidised healthcare is also one such instrument.
Poverty reduction and health outcomes are integrally linked as improved health outcomes contribute to reduction in poverty and vice versa. Several studies have shown that expenditure on healthcare is more effective in reducing poverty than expenditure on poverty alleviation programmes.
They have also revealed that a significant factor for the impoverishment of households is the lack of protection from the economic outcomes of ill health or death.
A major illness of just one member of the household (especially if he/she is the primary bread earner) can throw the entire family into poverty. This is borne out by both anecdotal and other evidence in Pakistan.
The poor and aged are forced to sell their assets or take massive loans to cover the costs of medical treatment and care. They are also exploited by indifferent health professionals in the public sector. They are caught in a vicious circle of poverty. The latter breeds ill-health which results in impoverishment and indebtedness. Hence, efforts to tackle poverty should consider the role of health, and health security should not be viewed as an end in itself but one for achieving the broader goal of poverty reduction.
Those hardest hit by lack of health coverage are the poor, who suffer from higher levels of mortality and malnutrition than the rich. A World Bank study on India shows that the poor-rich risk ratio is 2:5 for infant mortality and 1:7 for children underweight and that 24 per cent of the poorest quintile do not seek medical care when ill mainly because of poverty compared to nine per cent in the richest 20 per cent.
Furthermore, according to the World Bank, hospitalised Indians spend more than 58 per cent of their total annual expenditure on healthcare and almost 25 per cent of them fall into poverty every year as a direct result of medical expenses they pay on hospitalisation.
The point is that low levels of expenditure, poor quality of services, and inefficiencies have failed to provide decent health cover for the poor. This has raised the need for alternative financing mechanisms and instruments to achieve this objective, that is, health insurance to improve the access of the poor to health services — an instrument now being developed by insurance companies in the private sector for the more affluent households and for employees of corporate entities. The poor can also make small, periodic contributions that could go towards meeting their healthcare needs. Hence, the need for setting up a health insurance scheme for low-income groups.
The government of India introduced the Universal Health Insurance scheme targeting the poor in 2003. The premium was set at Rs365 per annum for an individual and Rs548 for a family of five.
The government gives a subsidy of Rs100 per family below the poverty line. The benefits include reimbursement of expenditure of up to Rs30,000 and illness compensation of Rs50 per day for the period of hospitalisation of the earning head of the family. There is a provision of coverage for Rs25,000 in case of death of an earning head of family in an accident.
The problem with the scheme is that the premium is too low for the insurance companies to offer good coverage and too high for the poor to pay upfront. Thus so far only two per cent of the policies have been sold to the people living below the poverty line. Pakistan, by learning from the experiences of India and other developing countries, can introduce its own scheme that addresses the kind of weaknesses identified here.
To make the scheme financially viable, the transaction costs for the insurance companies can be lowered by educating the people to buy insurance as a group contract (important characteristics for which would be age and sex of members) so that risks and contributions are pooled more effectively, while flexibility in payment of premium and the system of certifying claims and healthcare provision can be improved by the introduction of an agency that acts as an intermediary between the target community and the insurer.
For the poorest of the poor who cannot make any contribution, health insurance will not be relevant. For them there would be continuing need to provide free access to public health facilities or subsidised healthcare in private facilities. Health insurance as a financing mechanism would be appropriate only when part of the cost is recovered from the beneficiaries. It would make sense only when the beneficiaries are in a position to contribute something, provided, of course, this offers a means for the low-income groups to meet their priority health needs in a cost-efficient manner.
The writer is former finance minister, Punjab
A DISASTROUS combination of events the other day must have left many Muslims feeling battered. First MI5’s warning on the Islamist terror threat that suggested some 30 plots had been identified and support for violence was spreading. Then on Friday, the acquittal of the BNP leader Nick Griffin on charges of inciting race hatred for a covertly filmed speech that to many viewers was deeply offensive.
It may be by accident more than design, but the stakes are rising in a cultural conflict that should never have been allowed to gain traction. MI5 chief Eliza Manningham-Buller issued her alert alongside hints that she was concerned the development of parallel communities could worsen things. She is right. But in addressing that risk it is essential to recognise that Islam is far from the only factor pushing religion centre-stage.
Christian evangelism flourishes, partly in response to assertive Islam, partly encouraged by a surge in state support for faith schools that comes as the Anglican church flounders in the face of a schismatic tug of war between liberals and conservatives. Last year, the Archbishop of York, Dr John Sentamu, took his summer holiday in a tent praying for peace. Domestic politics became preoccupied by the veil. Two weeks ago, religion flexed its muscles when the Catholic lobby forced the education secretary to retreat from plans to dilute the intake of faith schools.
The Pope still has many divisions, more anyway than the backbenchers in the Commons who wanted to keep the government’s new city academies secular. So far 25, a quarter, are set to be Anglican or Catholic; several more are sponsored by evangelical Christians and at least two by the Baptist church. Muslim schools remain rare, but their number is growing. At the same time, more teenagers are studying religion at GCSE and A-level. The secularists’ retort, Richard Dawkins’ The God Delusion, is this year’s unexpected bestseller.
Now politicians intervene, rebranding the political divide as one of religion not class. Individual faith is politically sensitised, to be called in aid by the Christian right trying to prevent Turkey joining the EU, as much as by those who genuinely see describing it as a problem as the first step to solving it. In this context, there is a heavy burden on Britain’s Christian tradition.
To pretend there is no history of hatred between Islam and Christendom, nor any fundamental conflict in their theologies, is both absurd and dangerous. It has to be acknowledged. But it is a problem to overcome, not a legacy to be savoured.
Of course, Anglicanism is wrestling with its own internal difficulties. The evangelicals and liberals grow strident. But most Britons, whose Christianity is notional at most, are more likely to be repelled.
Friday’s warning — following the conviction of the terrorist Dhiren Barot — was a foretaste of the effects of allowing a full culture war to develop. But there is a basis for recovery.
Most people still see religion as a force for good in society; an acknowledged indicator of well-being. Christianity’s long march in lockstep with British socialism is a reminder of a shared concern, found in all faiths, for the weakest. But that is a far cry from yoking Christianity to Britishness, a course that can only widen the divide between the communities just when we all most need to work together. —Dawn/The Guardian News Service