Even though the subject is generally discussed as “education and health,” the sequence is being reversed herein as “health and education.” For, it is next to impossible to educate a people who are deprived of good health care facilities.

Food and health should take primacy over all other areas. While the interaction amongst the variables of health and education is a significant contributor to productivity and economic development; poor health care and condition, even in isolation, are a drag on economic growth and development efforts. It is, therefore, important to first know about the efforts made and that can be made to improve performance in this area in a country where over 35 per cent population falls below the poverty line and cannot afford good health cervices.

Come budget time and heightened concern is expressed about health and education. Budgeting, however, remains confined to a financial resource allocation exercise. Effective implementation and target attainment also requires organizational resources not just in the target sector but also in related sectors. Cross-sectoral linkages are important to see as efficient performance of related sectors is necessary for effectiveness in the sector under consideration.

As far as health expenditures are concerned, these have remained at 0.7 per cent of GNP since 1995-96 except for the years 1996-97 and 1998-99 when these were 0.5 per cent and 0.9 per cent of GNP respectively (Pakistan Economic Survey, 2000-01).

While it is all very well to exhort the government to allocate a higher share to health, we also know fairly well about the financial resource constraints. Tax revenue generation remains a major problem area. Import duties have been slashed. This loss has yet to be compensated by sales tax. Direct tax revenue generation has not increased significantly due to a pessimistic business outlook, growth-inhibiting measures taken as a part of the IMF’s reform effort, poor documentation, and tax evasion yet to be fought successfully. While all of the above feed into the resource crunch, a significant decrease in debt-servicing and defence expenditures is not foreseeable in the near future that would allow significant resource diversion to social sectors. We are, therefore, likely to be stuck with paltry percentage points of GNP for health and education in the years to come.

As for health, the target expenditure as per cent of GNP is 0.7per cent by 2004, 1.5 per cent by 2010, and 2.0 per cent by 2011 according to the perspective plan prepared by the Planning Commission. The international standard is 5 per cent of GNP. Even in the next nine years, we will be nowhere near the current international standard which might increase further until then thus becoming more elusive for us to attain. With the above low level of expenditure on health, Pakistan’s life expectancy (62.5) was only better than Bangladesh’s, Nepal’s and Bhutan’s in the South Asian region in 1999. Sri Lanka’s was a high of 73.5. Pakistan’s infant and under-5 mortality rates per 1000 were the highest in the region at 89.8 and 126 respectively.

Other indicators that speak volumes about the dismal state of health services include 1529 persons per doctor; 33,629 persons per dentist; 3,732 persons per nurse; and 1495 persons per hospital bed (PES, 2000-01). The above are not even spread out evenly in the country. With only 876 big urban hospitals, 5,171 basic health units, 531 rural health centres, 856 maternity centres, and 4,635 dispensaries (ibid); it is not too difficult to determine the population pressure on each. While the health delivery system may be widely spread, it certainly cannot reach out to each and everyone in the target group due to its paucity as compared to the population requirements.

The curative health facilities are, therefore, inadequate as everybody in the country should be provided with health facilities in line with their purchasing power. With around 65 per cent of the population below or around the poverty line, it is free or subsidized health service that is needed to maintain the health conditions of the deprived population in both urban and rural areas. This requires much more financial resources than the government can provide now or in the years to come. Also, medical benefits on the basis of actuals, if made mandatory for the low-paid staff in all organizations, would take some of the pressure off from public health service.

While the international financial institutions’s(IFIs} recipe calls for user charges and private sector’s role, it is entirely possible to mobilize financial resources from those affluent segments of the society who want to make a difference in spite of the existing politico-economic power structures in the country. Donation of a Rs22 crore medical complex for kidney treatment by a major business group in Fall 1998 indicates the immense pent-up philanthropic potential that can be tapped for the purpose. Subsequent donations were made by some financial institutions for the purpose of kidney treatment. In addition to local philanthropists, pharmaceutical MNCs in particular can also be approached for contributing towards a national health care scheme. For, in the past,the IBM contributed towards a computer literacy scheme during a Benazir government. Citibank contributed $1.2 million on March 15, 1997 towards Nawaz Sharif’s NDRP (a national debt retirement programme) to promote national goals.

User charges not in proportion to the poor’s ability-to-pay would remain burdensome and reliance only on the private business-oriented sector would require a return on investment that the poor would not be able to afford. IFIs’ recipe will keep health facilities inaccessible to the poor. Also, the opportunity cost of establishing fancy hospitals in urban areas needs to be determined in terms of the basic health facilities that could, instead, be provided with the same level of investment. Or, the opportunity cost of fancy hotels like a second one in Islamabad could also be gauged in terms of basic health units. Funds could be diverted for the greater good of the general public instead. Several steps could thus be taken towards financial resource generation for public health. As a first step, however, it is important to determine the total cost of setting up a countrywide health care system that would reach out to all. Sources of funds would be identified next. For this purpose, the policy makers would need to see far beyond the traditional foreign lenders (IFIs) to Pakistan.

Philanthropists and the socially responsible segments of the private sector would, however, contribute if an effective organizational blueprint is provided with the proposal. Confidence would need to be instilled in the contributors regarding effective utilization of their money. An organizational feasibility together with an implementation plan would be required in addition to a financial feasibility.

This brings us to the second issue of effective operation of the health facilities set up already. Poor management of these facilities is a second reason that keeps fuelling the demand for health care facilities. This issue emanates from a poor state of public administration in general and poor public health administration in particular. There is a need to formally engage experts in community and public health management in the preparation and execution of a national health scheme. These should be personalities who should be able to mobilize not just the financial and the organizational resources but also the latent philanthropic sentiment that is currently lying dormant. International sources of funds could also be tapped.

So, curative health service availability is closely tied to financial resource generation and public health management capability. In addition, there are linkages with sanitation facilities, clean water availability, hygiene, and nutrition as preventive measures. Sanitation and water are again issues in public administration. Hygiene and nutrition are functions of education and the levels of living which, in turn, is a function of the level of a country’s economic development. Even the issue of public administration cannot be divorced from the overall issue of economic development. Until then, however, the public administrators graduating from the various departments of public administration in the country could be formally engaged for improving public service delivery. As for the preventive measures being advertised by the government, the poor can ill-afford some of them like the use of mosquito repellents.

It is the sanitation department that should also be focusing on preventing the breeding of germs and mosquitoes through sprays, etc, instead of placing the entire onus on citizens. Health care cannot be divorced from issues in public health management and public administration. Despite the paucity of resources, a redeeming feature is the more effective polio vaccination campaign. Effort of the will is, therefore, needed to improve the health care service effectively. It should cease to be a function of a fraction of the GNP and should be seen in a wider context as above for improvements more rapid than what the small budgeted amounts and currently weak organizational capability can permit.

Education’s situation is no rosier than health’s. The expenditure on education as per cent of GNP ranged between 2.1 per cent and 2.5 per cent since 1991. Since 1998-99, the national education expenditure as per cent of GDP declined from 2.4 per cent in 1998-99 to 2.2 per cent in 1999-00 and 2.06 per cent in 2000-01. While the declining trend should certainly be reversed significantly in the coming budget, it is the utilization of available resources that remains problematic again due to poor management in this area as well. While there should be no reason for poor management of public education in urban areas if funds are made available, the rural areas will continue to pose resistance for as long as the old structures of rural power feel threatened from mass literacy and education. These rural structures are somehow replicated in urban public education system as well which continues to be a major hurdle in improved delivery at all levels from primary to tertiary.

While privatization is posed as a solution, it will make education unaffordable for the many as is obvious from the profiteering tendencies of the private school system. Even though education is supposed to be not-for-profit, it must generate surpluses to be ploughed back into the system. However, if the educational system goes overboard trying to generate surpluses, it will amount to restricting education to a narrow segment whose power poses to be a major hurdle for transformational change in the country. Education, being a double-edged sword, should be managed in a manner that it promotes development and not hinder it. It is for this purpose that literacy and universal primary education are promoted. It is important to note the caveats though.

Pakistan is reported to have made some gains in literacy. The literacy rate increased from 34.9 per cent in 1991 to 49 per cent in 2001. The official definition of literacy either remains unclear or disputed. For, literacy should mean the ability to read and write in the national language as is literally meant by literacy. Any shortcuts to merely inflate the figure of literacy on paper would not help achieve the objective. The world is supposed to open up on the truly literate as they start scanning and exploring materials and newspapers. Literates are then in a better position to find a place in the community, the society, and the world. The next level of their development is primary education. The extent of progress here would be known not merely from enrolments but from graduates after accounting for the dropouts which rate too is not low. Further, universal primary education is emphasized in development literature because of the direct impact it makes on sectoral productivity. While we have caught on, it is unclear what use will we be making of primary education if the majority in the countryside are not free to exercise initiative and enterprise in their fields due to concentrated landholdings and power. Similarly, with limited job opportunities, the primary school graduates are, at times, found to have also given up their traditional trade as they now seek desk jobs when few are available. Emphasis on universal education makes sense when the formal urban economy is creating jobs for the educated and the rural economy is creating opportunities for productive application. In the latter case, the primary school syllabi are customized for rural-agricultural application in the setting in which the student is likely to work. It is only then that education turns over into economic prosperity. Otherwise, it is the fringe economy that is likely to swell on the margins of affluence. This promotes a dualism that can be explosive. Inter-sectoral linkages of education are, therefore, more intricate than health’s. These links need to be appreciated and strengthened for a meaningful approach to education and development.