It appears to be a normal day at Jinnah hospital. The Outpatient Department (OPD) is clogged; the floor is covered with immobile bodies of patients and exhausted attendants. In some parts of the hospital, there is barely any room to move in this tangled mass of limbs and flesh. The scent of phenyl mixed with the stale smell of sweat permeates the corridors. The long, narrow hallways of the hospital, illuminated with only with dim and oft-broken light fixtures, surge with periodic shrieks of pain from an ailing patient or cries of grieving relatives.
All in all, if you are a patient with measly wage, Jinnah Hospital presents a dismal picture. With several patients sharing the same stretchers and overworked medical staff barely making it from one shift to the next, it is inevitable that patients will feel angry.
Qasim Awan, president of Young Doctor’s Association (YDA) Punjab, speaks of this growing dissatisfaction among patients. “Jinnah Hospital has a bed-to-patient ratio of 100 to 170. It is no surprise, then, that there is growing discontent among patients,” he says. “The government has been able to play this discontent to its own advantage by pitting patients against doctors,” he says. “The government pitches the MTI (Medical Teaching Institute) Act as a ‘wonder drug’ which will cure our healthcare system of all its ailments,” he says. “But nothing could be farther from the truth.”
What is the MTI Act Punjab? According to Awan, the MTI Act is synonymous with “complete privatisation of all medical teaching institutions of the Punjab and indiscriminate termination of all health subsidies for the poor.”
While Dr Awan is correct to some degree, the reality is a bit more nuanced.
The MTI Act Punjab is a 16-page draft bill, prepared by Dr Nausherwan Burki, a cousin of Prime Minister Imran Khan. The draft bill, which was modelled on the MTI Act of Khyber Pakhtunhwa passed in 2015, is currently awaiting approval from a standing committee of the Punjab Assembly. If approved, the bill will apply to all of medical teaching institutions of the Punjab.
While the bill does not completely privatise these institutions, it does seem to pave the way for doing so. The bill mandates the formation of a Board of Governors (BoG) for each institution. The members of the BoGs are to be selected by a search and nomination committee led by the provincial health minister.
“This is a process which will naturally be marred by nepotism,” Awan says. “Because of nepotism and corruption, the Supreme Court (SC) dissolved all the BoGs in KP,” he says, alluding to a June 2018 judgement by the then chief justice Saqib Nisar which declared the boards of the medical teaching institutions in the KP defunct and ordered the government to reformulate the boards.
The board, which has been termed as an “autocracy” by the YDA, will be the supreme authority of any medical teaching institute. It has the power to select a dean and a managerial committee to run the hospital on their behalf. The board also retains the right to terminate the dean or any member of his managerial committee at will. Moreover, the board will reserve the right to control and oversee the recruitment process and determine the terms of service of all MTI employees.
A core responsibility of the BoG will be to formulate a business plan and present a yearly budget. According to Awan, this will translate into an inevitable price hike. “The whole purpose of the MTI Act is to make these institutions more profitable. We saw in the case of KP how basic hospital charges surged after a similar experiment,” he says.
The BoGs, which can comprise of ten members, will have seven private individuals and only three government employees and even these three employees are excluded from policymaking because they do not possess a vote. This stipulation strengthens the idea that the MTIs are being privatised while, in fact, the government hospitals are being restructured into publicly owned autonomous corporations which are accountable (at least in letter) to the Provincial Policy Board (PPB). The PPB is a government body set up under the MTI Act to advise the government on how to run and improve MTIs.
Under this Act, doctors will have the option of running their private practices from the hospital OPD in their evening hours. In the draft bill, this is termed as ‘private practice’. Seemingly, this is a win-win situation whereby the doctors are able to charge exorbitant fees from private patients while the hospital also bags a 30 percent cut as a form of compensation for the infrastructure and amenities it provides.
Yet, Dr Awan points out some flaws in this model. “Introducing private practice in already overburdened hospitals would create an environment where private patients would be given preferential treatment at the expense of poor patients. We have already seen this dynamic play out in KP where private patients find themselves at the top of waiting lists while poor patients have to endure long waiting periods.”
Another provision of the act repeals the Punjab Civil Services Act 1974 (for the MTIs). It is clear that this provision is at the heart of the tug of war between health sector employees and the government. This provision implies that all of future employees of the MTIs will not be entitled to job security and benefits that come with being a civil servant and existing employees (consultants) will be given the option of remaining a civil servant or converting to the new framework spelled out by the MTI Act.
Agitation
The Young Doctor’s Association has come out in force against the Punjab MTI Act and have opposed it from day one. According to sources within the YDA, the organisation has been agitating against the proposed law for the past three and a half months. The protests and rallies picked up steam near the end of April, when several public demonstrations were held. This string of protests culminated in a consolidated province-wide OPD strike which began on May 2, and was formally called off on May 12.
The YDA is not the only body protesting the MTI Act. One May 6, the Grand Health Alliance (GHA) of the Punjab was announced. The GHA is a union of the Punjab Paramedical Staff Association (PPSA), the Young Nurses Association (YNA), the Punjab Specialist Association (PSA) and YDA. At the core of the alliance is the joint action committee which consists of one member representing each of the allied associations.
The GHA staged its biggest protest on May 9 in front of Jinnah Hospital. During this protest, hundreds of health workers blocked the road and demanded that the MTI Act be repealed.
While Dr Awan seems confident about the status of the on-going negotiations, not all of his allies agree. “It will take the government one year to implement the MTI Act if there is no agitation from us. They will still be able to roll it in in two years if we choose to continue our struggle,” predicts Arshad Butt, president of PPSA while addressing a meeting of the PPSA central committee.
Butt, who is also a member of the GHA committee negotiating with the government continues, “Our primary goal during the negotiations is to make sure that the current and the future lower staff remain government employees and there are no firings.”
The lower staff will be most vulnerable to the adverse effects of the MTI Act. “There have been reports of mass firings in the KP,” says Dr Farhan Gohar, a member of the YDA. The PPSA members agree. Danish Mughal, a PPSA representative, explains how the profit motive and the consequent outsourcing of hospital amenities impact the lower staff. “In Services Hospital, janitorial staff used to be government employees. The management decided to outsource the hospital clinic to a private contractor who was required to hire a 100 janitors,” he recalls. “The contractor only failed to do that, but also failed to pay the new staff the legally set minimum wage or provide them with retirement benefits and job security. We will see an exponential rise in such outsourcing of amenities after the MTI Act,” he says.
“There is an alternative,” says Hamid Riaz, the general secretary of the YDA. Riaz says that he has tabled these alternatives at his meetings with the government. “The health budget of this country is 0.6 percent of the GDP while the internationally accepted health budget should take up at least six percent of the GDP,” he points out. Hamid explains that increase in the health budget should be used for capacity building, which includes construction of new hospitals, upgrading old ones and hiring new human resources. Drawing from his experiences in Cuba, Dr Hamid Riaz recommends, “Poorer countries like Pakistan should have well-equipped basic health units (BHUs), district headquarters (DHQs) and tehsil headquarters (THQs) so the burden on bigger government hospitals can be reduced.”
Sharing details of the on-going negotiations with the government, Hamid says that the first meeting was held on May 16. Issues pertaining to price hikes for patients, service structure and low wages for doctors were discussed.
“In a recent meeting on May 20, we made it clear to the government that the employment status of healthcare employees should not be changed, hospitals should be run as welfare institutions instead of corporations, and poor patients should be provided with free healthcare in the evening,” says Hamid Riaz.
Now the ball is in the government’s court because the GHA has promised mass protests after Eid-ul-Fitr, if their demands are not met.
All this while, the unattended patients of Jinnah hospital remain unaware of the tussle and are simply awaiting treatment.
The writer is a journalist based in Lahore
All in all, if you are a patient with measly wage, Jinnah Hospital presents a dismal picture. With several patients sharing the same stretchers and overworked medical staff barely making it from one shift to the next, it is inevitable that patients will feel angry.
Qasim Awan, president of Young Doctor’s Association (YDA) Punjab, speaks of this growing dissatisfaction among patients. “Jinnah Hospital has a bed-to-patient ratio of 100 to 170. It is no surprise, then, that there is growing discontent among patients,” he says. “The government has been able to play this discontent to its own advantage by pitting patients against doctors,” he says. “The government pitches the MTI (Medical Teaching Institute) Act as a ‘wonder drug’ which will cure our healthcare system of all its ailments,” he says. “But nothing could be farther from the truth.”
What is the MTI Act Punjab? According to Awan, the MTI Act is synonymous with “complete privatisation of all medical teaching institutions of the Punjab and indiscriminate termination of all health subsidies for the poor.”
While Dr Awan is correct to some degree, the reality is a bit more nuanced.
The MTI Act Punjab is a 16-page draft bill, prepared by Dr Nausherwan Burki, a cousin of Prime Minister Imran Khan. The draft bill, which was modelled on the MTI Act of Khyber Pakhtunhwa passed in 2015, is currently awaiting approval from a standing committee of the Punjab Assembly. If approved, the bill will apply to all of medical teaching institutions of the Punjab.
While the bill does not completely privatise these institutions, it does seem to pave the way for doing so. The bill mandates the formation of a Board of Governors (BoG) for each institution. The members of the BoGs are to be selected by a search and nomination committee led by the provincial health minister.
“This is a process which will naturally be marred by nepotism,” Awan says. “Because of nepotism and corruption, the Supreme Court (SC) dissolved all the BoGs in KP,” he says, alluding to a June 2018 judgement by the then chief justice Saqib Nisar which declared the boards of the medical teaching institutions in the KP defunct and ordered the government to reformulate the boards.
The board, which has been termed as an “autocracy” by the YDA, will be the supreme authority of any medical teaching institute. It has the power to select a dean and a managerial committee to run the hospital on their behalf. The board also retains the right to terminate the dean or any member of his managerial committee at will. Moreover, the board will reserve the right to control and oversee the recruitment process and determine the terms of service of all MTI employees.
A core responsibility of the BoG will be to formulate a business plan and present a yearly budget. According to Awan, this will translate into an inevitable price hike. “The whole purpose of the MTI Act is to make these institutions more profitable. We saw in the case of KP how basic hospital charges surged after a similar experiment,” he says.
The BoGs, which can comprise of ten members, will have seven private individuals and only three government employees and even these three employees are excluded from policymaking because they do not possess a vote. This stipulation strengthens the idea that the MTIs are being privatised while, in fact, the government hospitals are being restructured into publicly owned autonomous corporations which are accountable (at least in letter) to the Provincial Policy Board (PPB). The PPB is a government body set up under the MTI Act to advise the government on how to run and improve MTIs.
Under this Act, doctors will have the option of running their private practices from the hospital OPD in their evening hours. In the draft bill, this is termed as ‘private practice’. Seemingly, this is a win-win situation whereby the doctors are able to charge exorbitant fees from private patients while the hospital also bags a 30 percent cut as a form of compensation for the infrastructure and amenities it provides.
Yet, Dr Awan points out some flaws in this model. “Introducing private practice in already overburdened hospitals would create an environment where private patients would be given preferential treatment at the expense of poor patients. We have already seen this dynamic play out in KP where private patients find themselves at the top of waiting lists while poor patients have to endure long waiting periods.”
Another provision of the act repeals the Punjab Civil Services Act 1974 (for the MTIs). It is clear that this provision is at the heart of the tug of war between health sector employees and the government. This provision implies that all of future employees of the MTIs will not be entitled to job security and benefits that come with being a civil servant and existing employees (consultants) will be given the option of remaining a civil servant or converting to the new framework spelled out by the MTI Act.
Agitation
The Young Doctor’s Association has come out in force against the Punjab MTI Act and have opposed it from day one. According to sources within the YDA, the organisation has been agitating against the proposed law for the past three and a half months. The protests and rallies picked up steam near the end of April, when several public demonstrations were held. This string of protests culminated in a consolidated province-wide OPD strike which began on May 2, and was formally called off on May 12.
The YDA is not the only body protesting the MTI Act. One May 6, the Grand Health Alliance (GHA) of the Punjab was announced. The GHA is a union of the Punjab Paramedical Staff Association (PPSA), the Young Nurses Association (YNA), the Punjab Specialist Association (PSA) and YDA. At the core of the alliance is the joint action committee which consists of one member representing each of the allied associations.
The GHA staged its biggest protest on May 9 in front of Jinnah Hospital. During this protest, hundreds of health workers blocked the road and demanded that the MTI Act be repealed.
While Dr Awan seems confident about the status of the on-going negotiations, not all of his allies agree. “It will take the government one year to implement the MTI Act if there is no agitation from us. They will still be able to roll it in in two years if we choose to continue our struggle,” predicts Arshad Butt, president of PPSA while addressing a meeting of the PPSA central committee.
Butt, who is also a member of the GHA committee negotiating with the government continues, “Our primary goal during the negotiations is to make sure that the current and the future lower staff remain government employees and there are no firings.”
The lower staff will be most vulnerable to the adverse effects of the MTI Act. “There have been reports of mass firings in the KP,” says Dr Farhan Gohar, a member of the YDA. The PPSA members agree. Danish Mughal, a PPSA representative, explains how the profit motive and the consequent outsourcing of hospital amenities impact the lower staff. “In Services Hospital, janitorial staff used to be government employees. The management decided to outsource the hospital clinic to a private contractor who was required to hire a 100 janitors,” he recalls. “The contractor only failed to do that, but also failed to pay the new staff the legally set minimum wage or provide them with retirement benefits and job security. We will see an exponential rise in such outsourcing of amenities after the MTI Act,” he says.
“There is an alternative,” says Hamid Riaz, the general secretary of the YDA. Riaz says that he has tabled these alternatives at his meetings with the government. “The health budget of this country is 0.6 percent of the GDP while the internationally accepted health budget should take up at least six percent of the GDP,” he points out. Hamid explains that increase in the health budget should be used for capacity building, which includes construction of new hospitals, upgrading old ones and hiring new human resources. Drawing from his experiences in Cuba, Dr Hamid Riaz recommends, “Poorer countries like Pakistan should have well-equipped basic health units (BHUs), district headquarters (DHQs) and tehsil headquarters (THQs) so the burden on bigger government hospitals can be reduced.”
Sharing details of the on-going negotiations with the government, Hamid says that the first meeting was held on May 16. Issues pertaining to price hikes for patients, service structure and low wages for doctors were discussed.
“In a recent meeting on May 20, we made it clear to the government that the employment status of healthcare employees should not be changed, hospitals should be run as welfare institutions instead of corporations, and poor patients should be provided with free healthcare in the evening,” says Hamid Riaz.
Now the ball is in the government’s court because the GHA has promised mass protests after Eid-ul-Fitr, if their demands are not met.
All this while, the unattended patients of Jinnah hospital remain unaware of the tussle and are simply awaiting treatment.
The writer is a journalist based in Lahore