Aurora Editorial: Mar-April 2021

If it is true that every cloud comes with a silver lining, then it can be argued that the one that came with Covid-19 shone a light on the fragility of Pakistan’s healthcare system.

A longstanding open secret for sure, but Covid-19 was the great equaliser; the virus that would (and did) strike at random, threatening in equal measure those secluded by high walls as well as those confined inside less salubrious quarters. In fact, by all accounts, in Pakistan, the virus appears to have had a higher incidence among the secluded – suddenly exposed to the frightening possibility of having to scramble for a hospital bed. And so, Pakistan’s fragile healthcare system became part of the national conversation.

It was perhaps this sense of impending national emergency that compelled the government, after several stumbles and irrational stops and starts, generously sprinkled with ridiculous pronouncements (remember the high ranking official who extolled the therapeutic virtues of a particular set of leaves?), to get on the page and manage the crisis. No doubt, Pakistan was fortunate that the virus – for reasons that are still subject to debate – did not create (thus far) the havoc witnessed in other parts of the world. However, credit must also go to the work done by the Ministry of Health and the National Command and Operation Centre (NCOC), in first managing the crisis and then working towards bringing the vaccine to Pakistan – although testing and tracing has left a lot to be desired. What this has demonstrated is that when the State wants to, it can rationally marshal the resources – and critically the experts – required to tackle a crisis. A question, cynical as it may be, is would this have happened in the way it did had it not been for the equalising factor of the virus.

The bigger picture is the healthcare system. The virus exposed a chronic shortage of even semi-functional hospitals as well as the shambles that passes as the primary and secondary healthcare sector in this country and the consequent burden placed upon tertiary care hospitals that are expected to carry an unnecessarily high patient load. At the heart of the issue is that historically governments in Pakistan have chosen to allocate about one percent of their overall budgets to healthcare. This is a shocking figure, and the reason why governments have been able to get away with this, is because we have a two track healthcare system. The minority who can afford to pay go to private sector hospitals and the rest who are left at the mercy of a crumbling public health infrastructure.

Are there solutions to this? The obvious one is for governments to substantially increase the nation’s health budget. But none have done this so far. However, the present government seems to be serious about trying to set up some sort of universal health coverage for the most deprived sections of the population. Started in KPK and with roll outs planned in other provinces, the Sehat Sahulat Programme, rudimentary as it is now, may prove to be a significant game-changer, despite a thousand ifs and buts along the way. However, the scope of what is required to give public healthcare a level of acceptable functionality is so vast that the government will have to further work in tandem with the private sector and enter into collaborative partnerships.

Another crucial area is the pharmaceutical industry, which although organised and functional has its own quirks; a market ostensibly serving a population of 220 million people, worth only three billion dollars, and fragmented in 700 companies that deliver only 10% of its total output to the public health sector. Then there is the fact that the pharmaceutical companies are hamstrung by policies fixated on controlling the prices of drugs (rupee devaluation notwithstanding), rather than their quality. A short-sighted policy that is preventing these companies from, among other things, taking advantage of opportunities to export to highly regulated markets or entering into contract manufacturing agreements with foreign partners. The result? The total export worth of Pakistan’s pharmaceutical products stands at about $300 million, when it could potentially reach five billion dollars. Ludicrous to say the least.

The crux is that there is not enough government intervention and support in some areas and too much in others. Public health is too critical not to be managed by the government. More money has to be ploughed into it. At the same time, governments need to understand the difference between oversight and interfering with the expertise of the people and institutions tasked with delivering on the job. The government must also be ready to take on board their recommendations on policy, while ensuring transparency and an efficient and equitable delivery of services.

The third wave of the pandemic is beginning to hit. How Pakistan will fare in this round is anybody’s guess. The roadmaps on how to navigate Covid-19 are still being written. However, there are plenty of good roadmaps about how to address Pakistan’s health crisis; what is required is the will of the State to do so. We now know that when it comes to the crunch, this ‘will’ can come to the fore. But must we wait for a national crisis to galvanise governments to do the right thing by their citizens? Pakistan’s healthcare system needs reform and rehabilitation. Public opinion did count for something during the pandemic; this same public opinion needs to keep the pressure up because it is upon the health of a nation that our own depends, whether we are protected by walls or not.