Delivering health

Published March 31, 2020
The writer, a public health consultant, is the author of Patient Pakistan: Reforming and Fixing Healthcare for all in the 21st Century.
The writer, a public health consultant, is the author of Patient Pakistan: Reforming and Fixing Healthcare for all in the 21st Century.

THE Medical Teaching Institution (MTI) Act was finally bulldozed through the Punjab Assembly this month. Its passage has come hard on the heels of a bill being hastily implemented through an ordinance last year, despite fierce opposition from representatives of the Grand Health Alliance. Built on the model of Khyber Pakhtunkhwa’s MTI, which remains controversial three years into its implementation, the law seeks to push privatisation of public sector hospitals through the back door, while dispensing with job security and pensions for health workers, allegedly in deference to IMF dictates.

The MTI places tertiary care under the administration of a board of governors who will take over the running of the hospitals, holding the power to hire, fire and turn hospitals into profiteering ventures. While these measures will definitely meet the needs of the creditors and prune government spending, the damage to the public-sector hospital work ethic, public service ethos and job security of the all-important medical and paramedical staff will be vast and irreversible.

The MTI affords staff the option of either staying within the new hospital service structure on a contractual basis, or returning to the parent health. The new staff hired under the MTI-led arrangement will be engaged on rolling contracts with no right to pension or long-term job security. This reinforces the impression that the MTI’s aim is to reduce government spending through contract and withdrawal of the pension facility, in addition to cutting expenditure on medicine and laboratory tests. Not surprisingly, the young doctors, more interested in job security and patient welfare during their idealistic career phases, have been at the forefront of the anti-MTI campaign.

Despite government claims of the MTI being a reform-minded measure, it is in fact the beginning of the creeping privatisation of the public health sector. In the UK, similar measures in the National Health Service have been dubbed as the ‘marketisation’ of tax-funded public health services. In Punjab, the MTI is being paraded as a measure to serve poor patients better.

The MTI is taking us to a fully privatised healthcare system.

However, reports have suggested that the patients accessing hospitals will be segmented into affording, entitled and non-affording and non-entitled categories. This discrimination will deprive the poor patient of free healthcare. Some, undoubtedly, will be directed to the insurance route, which covers only a fraction of the poor and vulnerable population. In this way, the MTI also promotes health insurance systems, which are not ideal as they always leaves a large chunk of the population uninsured. Further, cash-starved governments cannot cover insurance for all the vulnerable. For instance, even the Obamacare Act could not extend insurance to the entire population of the US.

I have seen up close the operation of the full-blown health insurance based system in Lebanon and shudder to see it fully implemented in Pakistan. It is also being said the MTI is a classic example of public-private partnerships. Yet the MTI is a slippery slope to full-blown privatisation, particularly when the unvoiced purpose of the act is to reduce government spending on health. In the UK, public-private partnerships in health have been under fire for being inefficient, generating poor value for taxpayers’ money, encouraging private profits at the expense of public money, and offering poor outcomes and quality care for patients. Moreover, by allowing senior consultants to use hospitals as private clinics, the MTI is introducing the principle of marketisation in public sector hospitals.

More than six months into its implementation through the ordinance, one can already see its adverse effects in practice. At the district-level hospitals, the facility of free laboratory tests and free medicine has already been largely withdrawn or vastly diluted. Couple this situation with the spectre of rising drug prices, and the future direction of healthcare becomes clear. To all intents and purposes, the MTI pushes us down the road to a fully privatised healthcare system by gradually undermining the free healthcare safety net offered by the public hospitals system and its associated welfare-oriented, public goods ethos.

Political parties have proven themselves inadequate to the task of preventing the rollout of the MTI. It is high time the government rethought its strategy by meaningfully engaging with the opposition and the medical profession to restructure public-sector hospitals in a way that preserves the principle of free treatment and medicines at the point of entry for the most vulnerable and the taxpaying public.

The writer, a public health consultant, is the author of Patient Pakistan: Reforming and Fixing Healthcare for all in the 21st Century.

Twitter: @Arifazad5

Published in Dawn, March 31st, 2020



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