Healthcare system of a country intends to serve the basic health related needs of the population that determines the welfare of the society. The government has a major role of ensuring access of equitable services to all for accelerated development. A dynamic policy process is a prerequisite for improving the healthcare status of the people. Prioritization of the health sector on national agenda varies when comparing Pakistan to England’s case. The basis of political structure is somewhat similar but the means to deal with significant subjects prominently differs.
Pakistan, since independence has devised few detailed healthcare policies to cope with the needs of people. However, implementation of the policies has been lacking. England, on the other hand is a country which set up the National Health Service back in 1948 and functions on taxation. Citizens of England have access to the medical facilities free of cost through these rules. More attention is given to implementation rather than formulation which has proved to be useful to some degree in dealing with the needs.
Contrary to England, Pakistan formulated its first National Health Policy (NHP) in 1990, showing commitment to the health sector by increasing health expenditures up to 5% of the budget. The second National Health Policy was formulated after seven years in 1997. It was based on the concept of Health for All (HFA). The next NHP (2001) was again based on health for all approach. Ten major key areas identified to take collective action through NHP policy include reducing communicable diseases, addressing inadequacies in primary/secondary healthcare, promoting gender equity, correcting rural/urban discrepancy in the health sector and improvements in the drug sector etc.
Nevertheless, comparing Pakistan with England in terms of devolution of the health sector, England’s devolution proposals were worked on by local governments in 2015 and were finalised in 2016 under the Cities and Local Government Devolution Act 2016 which is still to be implemented in all the cities.
Although draft of another policy was developed earlier in 2010 but because of the devolution of power related to the health sector in the four provinces in 2011 (under the 18th Amendment), further action was not taken. Later, the federal and provincial governments agreed on a common Nation Health Vision (NHV) (2016-2025), but no action has been taken.
The policy making process in Pakistan is highly centralized despite of power devolution. Moreover, the federal government is also intervening in provincial government matters for example introducing vertical programs which threaten the role of provincial governments. The main objective of this decentralisation in Pakistan was to transfer the power from the federal to the local governments and to authorize the provinces to devise policies for health issues keeping in mind the needs of people as they are closer to the targeted population; to devolve decision making regarding health matters. Such an action did not prove to be useful as it caused confusion of power sharing among different tiers of the government with the main power of policy formulation residing with the politicians and bureaucrats.
Nevertheless, comparing Pakistan with England in terms of devolution of the health sector, England’s devolution proposals were worked on by local governments in 2015 and were finalised in 2016 under the Cities and Local Government Devolution Act 2016 which is still to be implemented in all the cities. Starting with its implementation, budget for health care in Greater Manchester was consolidated under Greater Manchester Joint Commissioning Board which is exercising the executive powers granted to it through devolution. The local councils in the city are strengthened as part of the plan to work on decentralization in its true sense. According to the Chair of the Greater Manchester Health and Social Care Partnership (GMHSCP) ‘lack of integration within the health service at lower level is seen as the hospitals do not talk to each other or to General Practitioners’. He believes that the devolution is working to some extent because the organizations are joining hands for better services. The lower tier will also have to commit itself to ensure strong integration. For further development, the schemes to ensure a healthy lifestyle like cycling, walking should be taken into account.
At the federal level, PKR 13 billion for fiscal year 2019-2020 have been allocated to Health Affairs and Services which is nearly 0.2 percent of the total budget.
Whereas in the case of Pakistan, the health sector still gets low priority in public policies and allocation of resources despite a positive link between economic development and a healthy society. The health care budget set by the provinces comprises of development and current expenditures. Focus on current expenditures is more while less attention is granted to developmental expenditures which is adding further misery to the overall health scenario in the country. At the federal level, PKR 13 billion for fiscal year 2019-2020 have been allocated to Health Affairs and Services which is nearly 0.2 percent of the total budget. In Punjab, the health budget has decreased by PKR 5 billion whereas Khyber Pakhtunkhwa has prioritized health on its agenda, the budget since 2018 has doubled. In Sindh, the health budget increased to 19% of the total provincial budget while PKR 34.18 billion have been allocated for Balochistan’s budget for the current fiscal year.
Comparatively, the health spending in England overall, has been constantly increasing over the years and the public health budget has been decreased by 85 million Pounds for 2019/2020. The expenditure as a percentage of the GDP in year 2016 of the health sector for the United Kingdom was 9.76% while that of Pakistan was 2.75%. The budget for NHS in England is growing; the local governments are pressurized to cut down the costs. Despite an increase in budget, the problems in both the countries are on the rise with shortage of staff, hospitals, beds; health of the rich is improving much quicker than poor.
Pakistan’s policies are usually driven from the successful practices of developed countries which are not usually realistic and applicable in case of Pakistan due to cultural, political and social differences.
However, contrary to Pakistan, the people of England can access the members of Parliament and raise their voice for every issue they face; this technically has the potential to create policy and change priorities of the government. The roles of all tiers of government are relatively clear; the central government strives hard to decentralize the decision-making process.
In sum, one can infer that Pakistan’s policies are usually driven from the successful practices of developed countries which are not usually realistic and applicable in case of Pakistan due to cultural, political and social differences.Taking an example of the recent polio drive and vaccination programs, due to opposition of religious sect, the polio eradication drive could not be successful as it was thought to be a Western propaganda. This created issues in the implementation because the root causes are not properly identified. In England, the issues at micro-level are systematically brought up by the members of the Parliament through agenda setting. Decentralizing the system in Pakistan down to the micro-level with a bottom-up implementation approach would provide an opportunity to bring in fundamental changes in the primary health care domain in order to make it more efficient, effective and easily accessible to the masses like the universal health care system of the England.
Sara Asad completed her internship from the Centre for Strategic and Contemporary Research.