Politics, Reform and Political Change – Journal
PUBLIC policies struggle to survive and reform programs stall in times of political change. At best, uncertainty surrounds them; at worst, they are discarded by political opponents when they come to power, especially if they are identified with previous rulers.
Policy implementation also slows during political turmoil. Politics must struggle to retain or regain momentum under a new administration. They try to cajole, readjust, tweak, change their dress and yet can die from lack of attention and from the reluctance and anger of the new masters. With a change of crew, the merit of a policy takes a back seat and political expediency takes the wheel.
Public policies, especially social policies, are usually the first to suffer as they are easy targets for short-sighted policies. Security, defence, energy, economy and trade are relatively difficult to manage, at least initially, but education, health, 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, with the tightrope politics that comes with it – it is pertinent to remember that good policies that will benefit the people must be retained rather than abandoned simply because the PTI government formulated them.
Lily: Health and macroeconomic policies
Let’s elaborate with a few varied examples from the health sector and see how political and social turmoil affects the spread of disease.
There is ample evidence that in polio eradication programs in Pakistan and other countries, election year results in polio cases. Shah Meer Baloch wrote in 2019: “After the 2013 general elections, the number of polio cases increased 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. In the first six months of 2019, 32 polio cases were recorded across the country…. His sobering conclusion was that polio cases increased after every political transition.
The good policies formulated by the previous government must be retained by the new configuration.
Let us now look at an important example of a health program and see how it evolved and survived through different governments and in different regions of Pakistan.
The country has seen phenomenal progress in the social health insurance system. At the national level, it was launched by Prime Minister Nawaz Sharif in 2016 as a health program for the poor. It was called “The Prime Minister’s National Health Programme”. Poor families in Islamabad, Punjab and Balochistan have benefited from this financial protection program in the event of hospitalization.
During the launch of the programme, the Prime Minister said: “I wish that the provinces which are not part of the program [Sindh and KP] also adhere to the scheme. It is not a question of politics. But it was above all a question of politics. KP was then managed by the PTI and they did not accept the federal offer, but nevertheless launched their own health insurance program – the Sehat Insaf card.
Fast forward to 2018, when the PTI formed the federal government. Sindh was ruled by the PPP which refused to be part of the program. Seeing this political tragedy, which was denying health insurance to the people of Sindh, myself, and later Dr. Faisal Sultan, convinced the Prime Minister to change the name of the card from the Sehat Insaf card to the Qaumi card Sehat, what finally happened.
We wanted to do this in order to isolate this important program from political change, so that it would not be identified with a particular political party. The PTI nevertheless used the map for political purposes by universalizing it. So what started as a healthcare financial protection scheme for those who couldn’t pay is now also available to the wealthy in Punjab, KP, Azad Kashmir, Gilgit-Baltistan and Islamabad. . It will then be difficult to support the program financially or to ensure the quality of services. More importantly, the rich can crowd out the poor.
What will happen to the program currently under the PML-N-led coalition government remains to be seen. I hope they bring it back to vulnerable populations and institutionally strengthen the program, and that with Sindh now part of the coalition government, the province will also consider introducing it.
Sometimes governments roll back reforms out of political enmity. My writing of this column was triggered by a recent article alluding to the proposed reversal of reforms to the Medical Council of Pakistan and the Higher Education Commission. Sooner or later, the authorities’ attention may turn to the National Institute of Health and the Law on the Reform of Medical Education Institutions and some other institutional reforms, including the establishment of various health regulatory authorities.
It would be a mistake to reverse the reform process simply because they were introduced by the PTI government. There should be a proper objective assessment before any change.
I hope the new government can make special efforts to strengthen primary health care in the country. Therein lies the real problem and therein lies the real solutions to providing essential health care.
About 70% of the country’s essential health services can be provided at the primary health care level. If primary health care is strengthened and its quality assured, it would ease the burden on tertiary level hospitals which are currently bursting under patient pressure. Also, it will increase the vital health indicators which are currently abysmal. Universal health coverage is not possible without strong primary health care.
Another critical area is meaningful engagement with the private health sector to achieve universal health care based on primary health care in the country. Our Ministries of Health themselves need institutional reform and a special cadre of civil service needs to be put in place for doctors and other health professionals. Currently, a physician can retire in grade 17 since there is no career path. These are some of the areas that the previous government aspired to change but could not make substantial progress.
The author is a former SAPM Health, Professor of Health Systems at Shifa Tameer-i-Millat University and WHO Advisor on UHC.
Posted in Dawn, April 15, 2022