When politicians talk about healthcare for the poor, they bring up insurance cards. That is an absolutely untenable idea under the available circumstances. Before we can have some form of universal health insurance we need some basic things.

First necessity is a medical system that can actually provide universal healthcare. This means primary, secondary and tertiary care hospitals and more basic healthcare clinics that are not only available but also accessible to every person that needs medical attention.

This medical infrastructure must also have the capability to provide all levels of medical care from sore throats all the way up to advanced cancer treatments. That of course requires physicians, ancillary medical staff, appropriate laboratories and technology.

The medical infrastructure I have mentioned above is expensive; expensive to build, expensive to equip and staff adequately and expensive to run properly. That is the problem if we want to have a universal healthcare system without any rationing.

The other part of the ‘insurance’ system our politicians keep talking about needs public or private sector insurance companies that collect enough premiums to be able to pay for medical care at all levels and at any hospital where appropriate treatment is available.

The basic concept behind a system of healthcare insurance is that the hospital or doctors (healthcare providers) taking care of a particular patient bill the insurance company (third party payer) for the service provided. If we add medicines in the list of insured services, we will automatically add pharmacies to the list of providers. This requires a detailed system of payment schedules and a vast bureaucracy to service this system of payments.

And most important is some way to make sure that the ‘provider’ sends a bill for the right treatment or service and that the ‘payer’ accepts the bill and pays what has been agreed on in a published schedule. What sort of a schedule you ask? Well what the insurance will pay for treatment of a simple sore throat, and then for an infected throat (strep throat) and then for tonsillitis and so on ad infinitum.

Having worked for more than three decades in an insurance-based system of healthcare, I can tell that Pakistan is just not ready for any such system. The problem in Pakistan is going to be corruption at almost all levels.

Medicare is a government-run insurance system that provides healthcare at heavily subsidised prices to all Americans above the age of sixty five. However, even in the US this government-run system is prone to corruption and bureaucratic bungling. Every year multi-million dollar scams are discovered.

Since subsidised healthcare insured by the government is limited to older citizens, the ‘Affordable Care Act’ better known as Obama Care was an attempt to provide affordable health insurance for all Americans.

Healthcare heavily or completely subsidised by the government is anathema to ‘conservative’ or ‘centre right’ politicians. During the Pakistan Muslim League-Nawaz government, attempts were made to privatise the existing public healthcare system.

What we need in Pakistan if we wish to provide healthcare to all citizens is to strengthen the existing public healthcare system. From the basic health units (BHU) all the way up to the tertiary care and specialised care hospitals.

Over the last few months, I have devoted a lot of space in these pages on how to improve the existing system. In brief, I will enumerate the more important steps that need to be taken. First, of course, is the creation of a dedicated and well paid public health system that includes doctors as well as nurses and other ancillary medical personnel.

The second step is to decentralise the system and let the local governments run all the hospitals and the local health centres. Along with decentralisation must come diversification so that the bigger hospitals in the semi-rural areas can also provide an enhanced level of medical care.

The third necessity is to provide basic preventive healthcare concentrated in the communities and villages. Maternal and childcare is the most important. And the entire gamut of childcare from immunisation all the way to nutritional support is needed.

Most people that have never worked in a tertiary care centre Like Mayo Hospital do not realise the tremendous financial burden a rural family has to bear having a family member treated in Lahore even if the actual treatment is relatively subsidised. Usually many family members move with the patient to the hospital and essentially camp out on the hospital grounds or in the corridors.

This relocation for the period of treatment means that all the family members in attendance have to pay for food and other daily needs. Often the primary bread earner or the family caretaker accompanies the patient stressing the entire family financially. Diversification of advanced care closer to the rural areas will decrease the need for patient’s attendants to travel to big cities.

Obviously advanced medical care cannot be diversified initially but once the semi-urban hospitals like the Tehsil and District Headquarter hospitals are upgraded, even more advanced types of care can be moved to these hospitals.

One of the major problems associated with free or relatively free medical care is the need for rationing of care. The need for rationing is based on relatively limited resources. A government-run medical system will always have less flexibility than the private sector hospitals.

In the US, there are few government-owned and run hospitals. But the government insurance pays a competitive fee for service therefore government-insured patients receive the same treatment as privately-insured patients.

In western countries where some sort of free or heavily subsidised universal healthcare is present there always are waiting times for routine tests and treatment. The only way to get around that is to pay out of pocket or have private insurance that allows treatment at private clinics or hospitals. This means that running parallel to the subsidised healthcare will be a private system for those that want ‘better’ care.

The ‘original’ example of this two-tier system was the Albert Victor Hospital (AVH) attached to the Mayo Hospital. AVH was and still is for ‘private’ patients while the general wards in the main hospital are for ‘non-paying’ patients. Most government-owned and run hospitals have this sort of an arrangement. The important prerequisite is that all patients receive similar medical treatment.

Here I wish to address an important issue. As I mentioned above, conservative or centre right politicians oppose the concept of government subsidised medical care. For them medical care is not a right but a privilege. Those patients too poor to pay for medical care should be provided through ‘charity’.

I have nothing against charity but I believe that medical care is a right and should be provided to all citizens irrespective of the ability to pay and that charitable donations should be used to augment and improve public healthcare institutions.

About a health insurance card, I would suggest that we already have a universal health insurance card. It is better known as the Computerised Nation Identity Card.