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Policy, reform & political change

Zafar Mirza
6-8 minutes

PUBLIC policies struggle to survive, and reform agendas get stalled

in times of political change. At best, uncertainty surrounds them; at
worst, they are scrapped by political opponents when they gain
power, especially if they are identified with the previous rulers.
Policy implementation also slows down during political turbulence.
Policies must struggle to keep or regain momentum under a new
administration. They try to cajole, readjust, tweak, change their
attire and yet may die for lack of attention and because of the
loathing and ire of the new masters. With a change of crew, a
policy’s merit takes a back seat, and political expediency takes the
steering wheel.
Public policies, especially social policies, are usually the first to
suffer as they are soft targets for short-sighted politics. Security,
defence, energy, the economy and trade are relatively hard to mess
around with, at least at the beginning, but education, health, the
environment, population welfare and rural development are easy
targets.
At a time when political change is taking place in Pakistan — and
what a dramatic and dangerous political change it is along with the
attendant brinkmanship — it is pertinent to remind one that good
policies that will benefit the people must be retained rather than
scrapped just because the PTI government formulated them.
Read: Health and macroeconomic policies
Let us elaborate with some varied examples from the health sector
and see how political and social turbulence affects the spread of
diseases.
There is ample evidence that in polio eradication programmes in
Pakistan and other countries, election year gives rise to polio cases.
Shah Meer Baloch wrote in 2019: “After general elections in 2013,
the number of polio cases rose to 306 in 2014 before dropping to 54
in 2015, 20 in 2016, and only eight in 2017. In 2018, another
election year, cases again rose to 12. Within the first six months of
2019, 32 cases of polio have been recorded across the country… .”
His sobering conclusion was that polio cases spiked after each
political transition.
Good policies formulated by the previous government must be
retained by the new set-up.
Let us now look at an important example of a health programme
and see how it has evolved and survived through different
governments and in different areas of Pakistan.
The country has witnessed a phenomenal advance in the social
health insurance system. At the national level, it was launched by
prime minister Nawaz Sharif in 2016 as a health scheme for the
poor. It was titled ‘PM’s National Health Programme’. Poor families
in Islamabad, Punjab and Balochistan benefited from this financial
protection programme in the case of hospital admissions.
At the launch of the programme, the prime minister said: “I wish
those provinces which are not part of the programme [Sindh and
KP] also join the scheme. It is not a matter of politics.” But it was
very much a matter of politics. KP was run by the PTI at that time
and they didn’t accept the federal offer, but nevertheless started
their own health insurance programme — the Sehat Insaf Card.
Fast forward to 2018, when the PTI formed the federal government.
Sindh was run by the PPP which refused to be part of the
programme. Seeing this tragedy of politics, which was denying
health insurance to the population of Sindh, I, and later Dr Faisal
Sultan, convinced the prime minister to change the name of the
card from the Sehat Insaf Card to the Qaumi Sehat Card, which
eventually happened.
We wanted to do this in order to insulate this important
programme from political change, so that it was not identified with
a particular political party. The PTI nevertheless used the card for
political purposes by universalising it. So what started off as a
financial healthcare protection scheme for those who could not pay
is now also available to the rich in Punjab, KP, Azad Kashmir,
Gilgit-Baltistan and Islamabad. This will make it difficult to
financially sustain the programme or ensure the quality of services.
Most importantly, the rich may crowd out the poor.
What happens to the programme now under the coalition
government led by the PML-N remains to be seen. I hope they take
it back to vulnerable populations and institutionally strengthen the
programme, and that with Sindh now a part of the coalition
government, the province will also consider introducing it.
Sometimes governments undo reforms out of political enmity. My
writing this column was triggered by a recent news item alluding to
the proposed reversal of reforms at the Pakistan Medical Council
and the Higher Education Commission. Sooner or later, the
authorities’ attention might turn to the National Institute of Health
and the Medical Teaching Institutions Reform Act and some other
institutional reforms, including the creation of various health
regulatory authorities.
It will be a mistake to reverse the reform process just because these
were introduced by the PTI government. There should be a proper
objective assessment before any changes are made.
I hope that the new government is able to make special efforts to
strengthen primary healthcare in the country. This is where the real
problem lies and this is where the real solutions rest for ensuring
essential healthcare.
Around 70 per cent of the country’s essential health services can be
provided at the primary healthcare level. If primary healthcare is
strengthened and its quality ensured, then it would take the burden
off tertiary-level hospitals which are splintering under patient
pressure at the moment. Besides, it will uplift vital health indicators
which are at the moment abysmal. Universal health coverage is not
possible without strong primary healthcare.
Another critical area is meaningful engagement with the private
health sector for realising primary healthcare-based universal
healthcare in the country. Our ministries of health themselves need
institutional reform, and a special public service cadre needs to be
developed for doctors and other health professionals. Currently, a
doctor can retire in Grade 17 since there is no career path. These are
some of those areas which the previous government aspired to
change but could not make substantial progress on.
The writer is a former SAPM on health, professor of health
systems at Shifa Tameer-i-Millat University and WHO adviser on
UHC.
zedefar@gmail.com
Published in Dawn, April 15th, 2022