Healthcare, not wealthcare


Emergencies have a crude way of driving home reminders regarding misplaced priorities. The recent outbreak of the dengue fever, particularly in Punjab, has harmed lives and livelihoods while at the same time exposing glaring weaknesses in our health care system.
Having a healthcare system with serious institutional weaknesses means we simply react to emergencies rather than planning for them. There is a lot of rhetoric and whereas rhetoric is always more therapeutic when you are venting, it is not a currency most favorable to dispassionate analysis. There are deeper issues here. The discussion and analysis must focus not on particular political parties or individuals but on institutional factors. After the passage of the 18th amendment to the Constitution of Pakistan, ‘health’ is now exclusively a provincial suspect. This obviously has the merit of clarifying things but the weaknesses of the healthcare system at present serve as a reminder of the extent of our problems.
Part of the explanation for the lack of a healthcare policy is structural imbalance. The skewed civil-military equation does not help matters. Therefore, the state of Pakistan has apparently always found provision of guns to those guarding her borders more important than the health of those living within her borders. Bottom line: looking after people’s health is not cheap and if enough money is not spent, things are not easy. However, money is not the sole issue. There also seems to be a failure of imagination and a baffling inability to grasp the extent of the issue. Neither the federation nor the provinces reflect much evidence of any critical thinking of having gone into their priorities regarding healthcare. This has literally made expendable the lives of Pakistan’s citizens — a huge number die every year because of lack of quality care and access. Lives are lost even though the diseases are not life threatening. It is criminally negligent when a society cannot prevent lives being lost simply because it does not care enough.
Quality controls, when it comes to healthcare, are inexcusably deficient. The latest example one can give from Punjab is the case of an intravenous infusion drug (Solvein Ringer Lactate Solution for injection BP) which was being used to treat thousands of dengue patients and was found substandard after it caused reactions such as shivering and collapse. Lives were lost—lives that could have been saved. That should have been saved. Even though the authorities ordered this product off the market after a few days, serious damage was done and quite possibly is being done each day. There is no evidence to suggest that efforts for the removal of this product from the market have been successful. Once a product makes its way onto a market, particularly one with informational asymmetries as severe as those in the healthcare market, its control and eventual removal requires herculean efforts. The fact that substandard drugs make it to the market, especially in times of crisis, represents a grave danger — one that can be prevented if there is an institutionalised will to fix things.
All provincial governments need to get their act together on quality control. I am not criticising the incumbent governments here — this is a failure of generations and priorities. But the incumbents must act now. Even though drugs and medicines are now a ‘provincial subject’, there is nothing stopping the provinces from coming together with the federal government to set up a revamped quality control organisation that carries out certifications and quality control checks. Any entity carrying out this function will require capacity building, adequate funding and an effective mechanism for deterring violation of its standards. By not putting in enough money and planning into healthcare, the government allows the private sector to step in. Not only is privatised healthcare more expensive for most, it has more dangerous fallouts.
Growing market power of private health care providers and a hands-off approach by government is unsustainable. Healthcare is one area where you cannot let the private sector control things. You cannot privatise costs, quality control or trust the market with people’s lives. With healthcare we cannot say, ‘let the market control things’.The argument is that if quality is not good enough, the market will reject it. But the market is skewed and providers of medical care have market power that they can and will continue to abuse.
And they do not have a stake in ensuring quality control because the system can withstand certain number of lives being lost in the normal course of things. It is not every day that something like the dengue virus will spread panic. And even when it does the lack of an adequate governmental quality control mechanism means more lives are lost.
But the market power of the private sector means that people will have little option but to come back to the same doctors and hospitals because you cannot say, ‘I refuse to be treated’. You, as the consumer in the private market, are helpless when it comes to healthcare! Our hope and our protector is our government. That is why the governments of all provinces must act before more lives are lost. Not only does the healthcare system need more money, it needs more deterrence to punish those who toy with people’s lives. Each business calculates the costs and benefits of unlawful conduct while weighing them against the likelihood of being caught. Right now, it is economically feasible for people to break the law and imperil people’s lives. It brings profits and little likelihood of punishment. This has to change. Healthcare and quality control reform is the need of the hour: train, fund and deter. The writer is a Barrister and an Advocate of the High Courts. He has a special interest in Antitrust law and is currently pursuing an LLM at a law school in Cambridge, Massachusetts.