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Duty vs charity

Access to free medical care is one part of the safety net that a welfare state must ensure

Duty vs charity

One of the important areas where modern liberal and conservative politics collide is concerning the welfare state and the ‘safety net’ that goes with it. Perhaps, the concept of a Muslim ‘welfare state’ is best encapsulated in a famous saying attributed to the second Caliph that “If a dog dies hungry on the banks of the River Euphrates, Umar (RA) will be responsible for dereliction of duty”. Clearly providing for ‘all’ was considered a duty and not an act of charity.

Modern concept of a ‘welfare state’ has evolved considerably from the times of the righteous Caliphate, but the basic concept that it is the ‘duty’ of the state to provide a basic safety net persists. And universal access to free medical care is one part of this safety net. Before I go further, I will like to explain my point about ‘duty’ versus ‘charity’ by taking the example of two different medical institutions that are both providing excellent care to the public but with a different perspective.

First we have the Shaukat Khanum Cancer Hospital (SKH) in Lahore run by Imran Khan. SKH is a ‘charity’ hospital where I was told a few years ago that roughly one third of the patients receive free medical treatment, another third receive subsidised treatment and a third pay a full price for treatment. Essentially, SKH provides treatment at a cost based upon a patient’s capacity to pay.

On the other hand, we have the Sindh Institute of Urology and Transplantation (SIUT), one of the largest kidney hospitals in Pakistan that performs hundreds of kidney transplants a year besides providing medical care for all sorts of kidney problems including ‘dialysis’ to thousands of patients every year. Yet every patient is treated for free irrespective of their ability to pay. SIUT is a ‘government’ hospital and the government provides a part of the budget while the greater component comes from private donations.

The comparison between these two institutions best explains the different concepts of medical care. SIUT maintains the idea the medical care is a right and all patients that need care should be provided such care irrespective of their capacity to pay. SKH, on the other hand, runs on the idea that medical care is not a ‘right’ but a ‘favour’ made available to deserving individuals from charitable contributions. And that the recipient of such a favour should feel obligated to the charitable donors for their largesse.

I joined the department of cardiac surgery in King Edward Medical College/University (KEMC/KEMU) as the head of the department in 2004. Around then, Chaudhry Pervaiz Elahi, the then chief minister of the Punjab, announced that ‘emergency room’ care in all public hospitals was going to be free for all patients.

If we accept the concept that medical care is a right for all citizens, then medical care must be decentralised and basic primary and preventive care must be made available at the local level.

Over the next year, ‘all’ medical care in Mayo Hospital was also made free. In my department, we performed more than two hundred and fifty complex heart operations including coronary bypass surgery and heart valve replacements for free every year. The patients were only required to pay Rs25 out-patient admission fees.

And that brings me back to where I started from. There are two opposing points of view as far as free medical care for all is concerned. First is that Pakistan is a poor country and as such the government does not have the financial capability to provide care for all for free and those patients that can pay should contribute to their care. The other point of view is that all patients should have free care made available and if the patients choose to contribute, that is a choice left to their discretion. Of course, patients that prefer can always seek care in the private sector.

Unfortunately, politicians prefer to build edifices that commemorate their time in government. The CM of the Punjab recently announced that a cancer hospital will be built in Lahore to provide ‘free’ care for cancer patients. A great idea and something that will indeed benefit many sick patients. But that illustrates the problem with healthcare in the public sector.

What about a 50-year-old woman that develops a cancerous ‘lump’ in her breast? She lives in a village or a small town where access to medical care is limited. Unfortunately, for her, the lump in her breast will become quite large before she seeks medical treatment. By then the cancer might be too advanced to be cured. So, if there was a system in which such a patient gets regular medical care, the cancer could be detected early enough to be treated effectively.

If we accept the concept that medical care is a right for all citizens, then two important conceptual changes on the part of our administrators and politicians must happen to make it possible. First is that medical care must be decentralised. Second, that basic primary and preventive care must be made available at the local level.

Besides prevention of serious medical problems like communicable disease and problems of maternal and child health, many chronic medical problems like high blood pressure and adult onset Diabetes can be treated very well at the ‘local’ level before they lead to serious problems like strokes and kidney failure. We already have a network of basic health units (BHUs) and rural healthcare centres (RHCs) and district and divisional hospitals. Obviously, these should be properly funded and provided with the required manpower and facilities to function effectively.

And also, the 50-year-old woman with a lump in her breast after early detection could undergo ‘curative’ treatment at the district level hospital. But that would require certain basic capabilities. First, the pathology service that can diagnose the problem based on a biopsy. Second, the surgical capability to perform the appropriate operation. Third, the medical capability to provide ‘chemotherapy’ (medicines to control the cancer). These services should be made available at the district hospital level. The capacity to provide ‘radiotherapy’ (special X-Rays) to destroy any remaining cancer can easily be outsourced to a specialised cancer hospital.

The same holds true for other problems like heart disease. Instead of building more specialised heart institutes, it would be entirely appropriate to provide specialised services like heart catheterisation and basic heart surgery in the larger district and divisional hospitals and all of the ‘teaching hospitals’ associated with different medical colleges. Of course, every ‘teaching hospital’ needs to have capability of treating all types of patients and also provide the training for future medical specialists.

Decentralisation of medical care and concentration on preventive care and early detection and treatment of chronic disease can make it possible to provide better care at all levels at a much reduced cost. This could make healthcare available for free to most people.

However, to successfully decentralise medical care, one important political aspect needs to be emphasised. That is of an effective local government system. If locally elected leaders are made responsible for running the local medical care systems, they will be vested in making them run properly. Presently, if a BHU, RHC or a district hospital does not run properly, nobody in the political or the bureaucratic hierarchy can be held responsible.

Syed Mansoor Hussain

syed mansoor hussain
The author has served as Professor and Chairman, Department of Cardiac Surgery, King Edward Medical University.

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