Even though almost nine years have gone by since the passage of the 18th Constitutional Amendment and the subsequent devolution of powers from the centre to the provinces; the historic amendment is still the basis of many a legislative and jurisprudential question.

Small provinces are naturally more concerned about the impact of devolution on various departments, especially education and health. However, the discourse gained political intensity in Sindh during the past year, ever since the Pakistan Tehreek-e-Insaf (PTI) came to power, which intends to roll back the 18th amendment.

On May 22, the Federal Ministry of National Health Services, Regulation and Control took over the administrative control of the National Institute of Cardiovascular Diseases (NICD), Jinnah Postgraduate Medical Centre (JPMC) and National Institute of Child Health (NICH), all situated in Karachi, previously under the Sindh government’s control.

According to a notification issued by the Ministry of National Health services Islamabad, in pursuance of Supreme Court (SC) of Pakistan’s orders and with the approval of Federal Cabinet on April 2, the three major Karachi hospitals were restored to the federal government and placed under the administrative control of Ministry of National Health Services, Islamabad.

Earlier, the Sindh government had approached the SC to hand over the management of the three hospitals to the province under the 18th Amendment. The Supreme Court in January this year rejected the Sindh government’s appeals regarding the ownership of these hospitals and ruled that Islamabad would continue to administer the JPMC, the NICVD and the NICH.

Appreciating the notification, Sindh Governor Imran Ismail in a tweet said that he was confident "these institutions will perform at their best and will become a model." He went on to say that "Board of Governors [for these hospitals] will be announced soon."

However, officials in the Sindh government said both the Pakistan People’s Party (PPP) leadership as well as the provincial government, are highly perturbed over the federal health ministry’s notification regarding the control of the hospitals. The Sindh government claims to have spent billions of rupees on the three hospitals, especially on the NICVD where satellite facilities and chest pain units were also set up by the provincial government.

Days before the apex court’s decision, the Sindh government passed a bill ‘Sindh Institute of Cardiovascular Diseases (SIDVD) Bill 2018’ in an attempt to completely rid the NICVD of the interference of the federal government. The bill, however, was returned by the governor with certain objections. The PPP, calling it an attack on provincial autonomy, decided in principle to halt the transfer of the three major hospitals of the province to the federal government till the Supreme Court heard the review petition filed by the provincial government.

The PPP leaders familiar with the development inform TNS that the Sindh Chief Minister Syed Murad Ali Shah is flying to Islamabad soon where he will take up this matter with Federal Adviser on Health Dr Zafar Mirza and other officials in the centre. It has also been learnt that the party leadership has tasked Senator Raza Rabbani to file an immediate application in the apex court for an urgent hearing of the matter.

"Sindh government had invested billions of rupees in revolutionary improvements in the JPMC, the NICVD and NICH after the hospitals were handed over to the province under the 18th amendment," Bilawal Bhutto Zardari, the PPP Chairman said in a statement. "The expansion of the NICVD hospitals to several cities in the province and paid for expensive cardiac treatments of patients from all over Pakistan shows Sindh government has done well here." He said that the Sindh government was spending Rs12.5 billion on the NICVD and Rs4 billion on the JPMC annually to ensure quality, free-of-cost treatments for patients from all over Pakistan.

The medical and paramedical staff of these hospitals have, however mixed reaction on the apex court’s order. Most of the employees, especially paramedical and support staff that opposed transfer of hospitals’ management to the provincial government are overjoyed at the announcement.

"The JPMC and the other two health facilities were at the forefront in providing best medical services, training and research and all of this was possible because of their federal status and freedom from local political influences," says Amjad Shabbir, a support staff working in the JPMC for the past twenty years. He says that the employees strongly feel that the Sindh government should work on improving hospitals that are already under their jurisdiction, such as the Lyari and Korangi hospitals, rather than focusing on gaining control of a hospital like the JPMC.

Also, because all the three hospitals were federal institutions initially, their employees usually come from all over the country. "Employees who are from other provinces never supported transferring of hospitals to the Sindh government as they were concerned about their jobs, increment in their salaries, bad management and the overall status of governance of the PPP’s provincial government. Control of the provincial government could also result in long term problems like nepotism, political interference and poor working conditions due to financial constraints," Shabbir says.

However, simultaneously, many feared that the PTI-led new federal government would be unable to run these facilities. Young Doctors Association (YDA) Sindh Chairman Dr Umer Sultan says that the federal government was facing an acute shortage of resources and even their own officials were puzzled how they would allocate financial and material resources to run these hospitals effectively. "This move by the PTI-led federal government might result in poor service delivery at these hospitals," Sultan says.

On May 30, a section of civil society activists in a press conference at the Karachi Press Club apprehended that the services of all these health facilities would be badly affected after the federal government’s takeover and that patients who are already poor might be charged heavily as was being done in the past.

The future of over 7,000 students of Jinnah Sindh Medical University (JSMU) and its affiliated colleges is at stake as the administrative control of Karachi’s three largest hospitals is returned to the federal government. All these facilities serve as teaching hospitals for these students.

Political analysts believe that after the passage of 18th Amendment the PPP, which traditionally wins in the rural parts of Sindh and not in the capital will gain more administrative control in Karachi. But the general view is that the party is still showing indifference towards the metropolis.

"This controversy over the three major hospitals is linked to the ongoing tussle between the federal and provincial governments over control. The PTI government is now settling the issue of the 18th amendment through the judiciary," says Tauseef Ahmed Khan, a Karachi-based political analyst. It seems the federal government will now empower the municipalities by giving the power back to elected mayors through the judiciary.