IN the paediatrics ward of the Rawalpindi General Hospital (RGH), it is common to find at least two or even more children sharing a bed. Arguments between parents and doctors regarding the availability of beds and quarrels among parents of patients over bed space are usual occurrences.

Recently, a patient went into hypothermia, a condition of abnormally low body temperature, because there were not enough blankets. Before that a child was badly bitten by a rat while he was in the dark toilet: either the bulb was fused or the electricity connection was not working.

One of the patients in the ward is a nine-month old baby boy from a poverty-stricken family, who has been diagnosed with cancer of the lymphatic system. His parents cannot afford the frequent platelet transfusions which form part of his treatment. These transfusions cost Rs300 a bag and they are not available at the hospital.

So far, his transfusions have been made possible by donations here and there from sympathetic doctors, nurses and parents of other patients in the ward. This is notwithstanding the existence of the zakat system and the Baitul Mal, and the fact that our subsidy-dependent public hospitals are supposed to provide all the necessary medications.

Given this picture, it is not surprising that, according to a report in this newspaper last week, an official survey has revealed that more than 64 per cent of the people in the country are dissatisfied with the standard of basic health services.

Despite the urban bias in the allocation of resources for public healthcare services and in the location of infrastructure of these services, it has been found that people in the urban areas are more dissatisfied with the standard of basic health services than the rural populace.

According to the survey, more than 70 per cent of people living in the urban areas are found to be dissatisfied with the health facilities whereas the figure is 59 per cent in the rural areas.

These figures only confirm the longstanding general perception of our public hospitals as being deficient in terms of both capacity and quality of health-care provided.

The problems in our public health system had earlier been thoroughly studied and analysed in 1991-1993 by the health ministry. The objective of this consultative study was to reform the organisation and financing of our health services by firstly, making more resources available and increasing allocation to health; secondly, improving the cost-effectiveness of health spending; and finally, ensuring the physical and financial access to basic health services for lower socio-economic status groups.

What emerged from the study was a set of five comprehensive volumes published in 1993 on “Policy options for financing health services in Pakistan”.

It recommended that Pims and Polyclinic be converted into autonomously-run entities over a 10-year period, to be followed later on by similar conversion of other public hospitals. These hospitals would receive indexed block annual subsidies from the government, which would diminish over a period of years, with substitute revenues being generated through user payments.

The study also envisioned that with control over their budget, personnel and service policies, autonomous hospitals’ Board of Directors and senior administrators would have the incentive — and the authority — to increase efficiency in hospital operations, contain costs and raise the quality of care.

The study also stated that the hospitals, which would remain under the ownership of government, would retain their social mission and continue to provide free care to those unable to pay. To ensure better funding services for those who are unable to pay, the study suggested that hospitals seek to develop an enhanced relationship with the zakat fund and that patient welfare committees responsible for identifying those who are unable to pay be improved.

The study recommended some other measures, including improvement in the salaries of all healthcare workers, responsiveness of support departments like laboratories and pharmacies, and the physical condition and regular upkeep of hospital buildings. The study also recommended the development of private health insurance.

It has been 14 years since this study was finalised, but nothing much has changed in our public hospitals. They are still almost totally dependent on government subsidies. According to the chairman of the Board of Management of Rawalpindi autonomous hospitals, this situation is unlikely to change in the near future. Since responsibility and authority are not delegated to managers in these hospitals, and there is no accountability either, discipline and morale are common problems, schedules are usually not adhered to, and resources such as supplies and equipment are often not available.

In short, most of our public hospitals are still inefficiently operated, with many resources being wasted, and the quality of healthcare remains low. Not surprisingly, health expenditure as a percentage of GNP remains pathetically low: it was 0.73 per cent in 1991-92 and 0.6 per cent in 2004-05.

Many will probably agree that the following grim analysis of our public hospitals, published in the above 1993 study, remains as true today as it was then: “... the government has been unable to provide adequate resources to maintain the level of services required for a growing population... Hospitals run by the government are experiencing severe financial strains. Their budgets are so inadequate that they are unable to provide a reasonable standard of care. As a result, the reputation of these facilities is extremely poor... Families with either sufficient personal income or access to government or private employee benefits or to insurance programmes, generally seek care at non-ministry of health facilities.”

In the 1980s, we had also tried in vain to experiment with limited autonomy in public hospitals, beginning with Pims, Sheikh Zayed Postgraduate Medical Institute and the National Institute of Cardiovascular Diseases (NICVD).

The latest attempt at reforming public hospitals began in the early 2000s. In 2002, Boards of Governors — later changed to Board of Management — comprising volunteers from the public were set up to supervise the running of public hospitals. For example, the three public hospitals in Rawalpindi now come under the Board of Management of Rawalpindi Autonomous Hospitals. But these hospitals are anything but autonomous in the true sense of the word.

Two factors seem to have been the major obstacles all along in our efforts to reform public hospitals. Firstly, the decision to grant autonomy is inevitably linked to the intention to privatise healthcare. Critics of privatisation in healthcare and thus “uninformed critics” of autonomy often feel that steps toward autonomy mean that the government is abdicating its social responsibility to protect the health of the citizens, specially the poor. Governments — military and more so civilian — therefore consider it politically suicidal to push for autonomy of public hospitals.

Secondly, autonomy is based largely on the principle of making those who have the resources, to contribute to the cost of the health services they use, mainly through paying user fees, often facilitated through insurance mechanisms and employer- contracted health plans for employees. But our bureaucracy, both civil and military, who has been enjoying the benefits of practically free medical treatment in public hospitals and often even free treatment abroad, naturally oppose this reform.

Unless we can achieve a breakthrough on these two sensitive issues, we will not be able to reform our public health structure and improve its delivery system. A breakthrough on these issues will require us to recognise the harsh reality that it is not economically feasible for the state to provide a full range of health services to all citizens. Unless those who can afford to pay are made to pay accordingly for public healthcare services, the majority of our poor will continue to be deprived of the full benefits of this service.

As for the inauguration of the Pims medical tower recently, it can at best be viewed with cautious optimism. Unless similar structural improvements are made in the 900 over other public hospitals in the country, accompanied by major organisational and health financing reforms in the management and running of these hospitals, nothing much is expected to change overall in our healthcare delivery system.

Commenting on People’s Party Parliamentarians’ demand for dismissal of the Sindh government and imposition of governor’s rule in Sindh, daily Kawish says the demand is not in conformity with democratic values and principles.

The rulers used this prescription whenever they wanted to rule this province according to their wishes. No person believing in democratic values can even imagine making such a demand. It is strange that this demand has been made by the country’s largest party which claims to be a champion of democracy.

The daily refers to the situation in other provinces which it says is not different from that in Sindh and asks why a democratic party chose Sindh for governor’s rule. The paper says that the PPP will have to come up with justification for making this demand.

Daily Tameer-i-Sindh also criticises the demand and says that governor’s rule is not a substitute for a democratic set-up.

The Sindhi press has taken notice of President Musharraf’s recent statement that distribution of financial resources on the basis of population is a correct decision.

Daily Kawish recalls that after taking over power the general had promised to remove inequalities and differences among the provinces. The National Reconstruction Bureau also held a series of seminars and discussions about provincial autonomy and at all these seminars and discussions, unanimous recommendation were made about provincial autonomy.

Financial resources are being distributed on the basis of population for years, against the wishes of smaller provinces, which have been questioning this formula.

Some studies were conducted under the sponsorship of the government which recommended inclusion of other factors, such as revenue generation and backwardness, in the formula for the National Finance Commission award. The paper says that after recommendations made in these studies, the government had agreed in principle to devise a formula to accommodate the viewpoints of smaller provinces.

But when time came for decision making, these recommendations were set aside as the Punjab refused to accept a new formula based on any other than factor except population.

The papers says that people living in smaller provinces are also Pakistani citizens and they too must get their rights and due share in national resources.

Daily Tameer finds it strange that Sindh remains poor despite being rich in resources and contributing a big share to the federal pool. The paper says that other provinces are drawing 150 to 250 per cent of whatever they pay to the federal kitty but Sindh is treated differently. It pays its thirty days’ income to the federal pool but receives the equivalent of one day’s revenue.

All major Sindhi papers have commented on the recently held Kotri and Karachi by-elections and have expressed reservations about the way they were held.

Daily Ibrat says that free and fair elections are among the elements of democracy but it was not so in the case of the by-elections with reports of clashes, firing and rigging. The paper says that the government, law-enforcing agencies and the election commission failed to play their due role. The paper says that general elections are expected by the end of this year. Is it possible for the government and other relevant authorities to hold free, fair and peaceful elections?

The paper demands the setting up of an independent election commission and an impartial caretaker government to ensure free, fair and impartial elections.

Welcoming the recent bill on women’s rights - the Prevention of Anti-Women Practices - daily Awami Awaz says that the passage of the bill alone is not sufficient; more important is its implementation in letter and spirit. The paper says that statements are issued and claims are made for political gains.

The paper recalls the amendments to the Hudood ordinance and asks if women have got their rights and protection. According to the paper, the ground situation is entirely different; women have been humiliated more during the present regime than in previous days. “We have law but no enforcement, we have administration but no peace; we have courts but no justice.”

Criticising the writing off of Rs35 billion loans, daily Koshish terms it startling and says that it proves that government claims about transparency in financial matters are not credible. It is believed that the people who were bestowed with these concessions enjoy the patronage of people in authority. The paper says that the banks and financial institutions in public sector are property of the people; hence no one has the right to waste this money by writing off loans. The paper demands publications of names and purpose for which the loans had been given.

Daily Hilal-i-Pakistan refers to the cases of Nasima Labano, Kainat Soomro and Sakina Solangi, all victims of violence. Nasima and Kainat were gang-raped while Sakina suffered acid burn injuries.

The paper gives credit to the media and some NGOs for making their cases public otherwise, it says, hundreds of women are being subjected to rape, violence and other excesses, and forced to keep quiet. The paper urges the government to reach out to such women who have to keep quiet for one reason or the other.

One month in cricket is a long time. In Pakistan cricket, it’s an eternity. A lot can happen in an eternity. Fortunes can be transformed, empires can rise and fall, cricket teams can go from zero to hero.

The Bible says God took six days to make the world. Well, between now and Pakistan’s opening match in World Cup 2007 (against West Indies on Tuesday, March 13), He’s got twenty one. Our team is in need of miracles. God can help with that. National disappointment at Pakistan’s poor showing in the South African ODIs may be understandable, but it is still an over-reaction. For one, the defeats were hardly anything new, as it is well recognized that Pakistan has a South Africa problem. Pakistan wins fewer than 32% of its ODIs against South Africa (the worst against any team), compared with 39% against Australia, 40% against West Indies, 42% against England, and as many as 64% against India.

In fact, Pakistan has won an ODI series everywhere in the world – except in South Africa. Even in Australia we’ve won twice (the Carlton and United triangular in 1996-97 and a best-of-three Super Challenge in 2002), but South Africa still eludes.

Even so, but for a twist of the weather, the result could have been different. Instead of wallowing in depression and dismay, we could have been worrying about brashness and complacency. Had it not rained in the 3rd ODI at Port Elizabeth, Pakistan could well have been 2-1 up going into the 4th match at Newlands. Confidence being what it is, anything could have happened. What did happen, unfortunately, was the rain, and it proved to be the final straw. After nearly pulling off an impossible Test series win at Cape Town, and clawing their way back into a bitter ODI series after the mauling at Centurion, Pakistan collapsed in exhaustion under the pelting rain. Granted they are professionals, but even professionals are human.

The hallmark of a great side is its ability to immediately put disappoints behind and move on. Look at Australia. They might drop a dolly catch at a crucial moment, but it gets erased from memory right away, and next delivery they’re back fighting with the same tenacity and vigor. Australia, as it turns out, have just lost five of their last six ODI matches, including the Commonwealth Bank title to England and a 10-wicket loss to New Zealand. But you can be sure it’s not going to clutter their minds. Ruing the past is counter-productive, and the sooner you can get it out of your system the better.

If anything, there is good reason for Pakistan to look ahead to this World Cup with anticipation and hope. It is such a talented team. Even in the worst-case scenario, with none of the frontline seamers available to play (due to doping and/or injury), they are still capable of outplaying anyone on a good day. Often, that’s all you’ll need in the World Cup.

It is (perversely) comforting to be reminded that Pakistan’s title-winning ’92 World Cup campaign had also been born in uncertain circumstances. First, a home ODI series against West Indies was lost 2-0; then Waqar Younis, Pakistan’s ace of spades, pulled up injured; and finally the selectors lit a flame of controversy by dropping Javed Miandad from the World Cup squad.

Performance in the pre-tournament preliminaries was abysmal, prompting a call-up for Miandad, who spent the long hours of his flight to Australia wondering if, as the press had been saying, he was really finished as a batsman. Miracles were needed, and they happened. Miandad still credits the blessed month of Ramazan, during which the tournament had been played. Imran pays tribute to the noble mission of setting up a cancer hospital from the championship boost.

There is every reason to believe that Inzamam and Woolmer will now be as hungry for the title as Imran and Miandad were in 1992. Woolmer almost tasted it in 1999, when he was South Africa coach; and Inzamam, of course, actually tasted it in 1992, though not as captain. In the twilight of his career, Inzamam now sits in that stratosphere of cricket achievement where legacy matters more than anything else. He will be willing to sacrifice an arm and a leg, and much else besides, to be spoken of in the same breath as Imran and Miandad. He is almost there, but not quite. A successful World Cup 2007 can secure such exalted status.

Pakistan can also take heart that teams from the subcontinent have, over the years, emerged as a kind of World Cup elite. The major subcontinental teams – India, Pakistan and Sri Lanka – have each held the World Cup at some point even though frontline sides such as England and South Africa have yet to do so. Each of the last four World Cup finals, in fact, have included a team from the subcontinent – Pakistan in ‘92, Sri Lanka in ‘96, Pakistan again in ‘99, and India in 2003.

This time we can even see the outlines of a tantalizing parallel. Back in 1983, West Indies ruled the world and were everybody’s choice as the team to beat. They marched into their third straight World Cup final on the back of two consecutive titles, only to be felled by India. In 2007, Australia are the supreme power and they come into the tournament fuelled by the momentum of two titles in a row. It is tempting to speculate there is a subcontinental sting in the World Cup tail yet again.