The fire at the Pakistan Institute of Medical Sciences (PIMS), which claimed the lives of 14 newborns, provoked an entirely justified public outcry. Citizens demanded answers, accountability and punishment for those responsible. Under mounting public pressure, the Shehbaz government suspended senior administrators, including the head of the institution, and ordered an inquiry. A judicial inquiry was subsequently announced.
For a moment, it appeared that public pressure had succeeded in placing the question of responsibility at the centre of the debate. Then came a seminar at Islamabad’s Black Hole, titled “The PIMS Fire and the Way Forward,” with the participation of Dr Zafar Mirza, Quaid Saeed and Amjad Mahmood.
One might reasonably have expected the discussion to focus on the circumstances that led to the deaths, institutional safety, administrative negligence and the responsibility of senior management. Instead, the central prescription was managerial autonomy.
The argument was that public hospitals should continue receiving state funding but operate with greater independence from government ministries. Hospital administrations, it was suggested, should possess extensive powers over recruitment and dismissal, while retiring permanent employees could increasingly be replaced with contract workers.
The tragedy that demanded accountability was thus transformed into an argument for granting management greater power. This shift deserves serious scrutiny.
Dr Zafar Mirza’s position reflects a familiar argument in contemporary health policy, that is, that the state should finance public hospitals but refrain from excessive interference in their administration. According to this approach, hospitals require autonomy to recruit, dismiss and manage their workforce efficiently.
However, autonomy without accountability produces a fundamental democratic contradiction. If a hospital is publicly financed, who is responsible for the decisions made within it?
The answer cannot be that the state must provide the money but has no right to question how that money is used. Nor can hospital management be granted extensive administrative authority while responsibility for institutional failure remains unclear or dispersed.
Public hospitals are not ordinary service-delivery units. They are social institutions sustained by collective resources. Their buildings, equipment and salaries are financed directly or indirectly through public expenditure. Their patients are citizens exercising a social right, not consumers purchasing a commodity.
Those who finance public institutions therefore have a legitimate interest in how they are governed. Managerial autonomy becomes dangerous when it is detached from democratic oversight. Autonomy for management cannot become immunity from accountability.
This debate must be situated within the wider political economy of Pakistan’s health sector. Over the past decades, public institutions have increasingly been subjected to reforms based on managerial autonomy, outsourcing, public-private partnerships, contractual employment and private or semi-private administration.
The language may differ, but the underlying logic is often similar, that is, the state continues to finance social services while gradually surrendering direct control over their administration.
This does not always resemble privatisation in its traditional form. A hospital does not need to display a sign reading “Privately Owned” for privatisation to take effect in practice.
The state provides the funding, while management retains the authority to make crucial decisions. Workers face insecure employment, weakened unions and deteriorating conditions. Patients face the consequences of administrative negligence, institutional failure and inadequate oversight.
The state pays. Management decides. Workers carry the risk, while patients bear the consequences.
This is not the democratisation of public healthcare. It is the concentration of public power within increasingly insulated managerial structures.
The question becomes even more significant when charitable and trust-run hospitals receive substantial public funding. During the 2022 interim government in Sindh, the then health minister raised questions about the distribution of government funds between Karachi’s public hospitals and major trust-run institutions. He cited annual government grants of approximately Rs8 billion for Civil Hospital Karachi, compared with around Rs16 billion for SIUT and Rs12 billion for Indus Hospital.
The issue is not whether trust hospitals should necessarily receive less public funding. The central question is how public money is governed.
When billions of rupees are transferred to institutions operating outside conventional government structures, their budgets, expenditures, governance arrangements and performance must remain subject to transparency and public scrutiny. Public financing creates a public obligation. The fact that an institution is managed by a trust, foundation or autonomous board does not transform public money into private property.
Nor does the existence of a board automatically guarantee democratic accountability. The crucial question is simple: accountable to whom?
If the answer is only “the board”, citizens are reduced to the role of financiers without gaining any meaningful role in governance. That is public financing without public control.
The problem with technocracy is not that expertise is unnecessary. Hospitals require medical, administrative and technical expertise. The problem begins when expertise is used to remove questions of power from public debate.
Institutional crises are then reduced to problems of management, efficiency and procedure, while their political and economic foundations disappear from view.
Why is a hospital underfunded? Who controls procurement? Who makes senior appointments? How are contracts awarded? What happens to complaints? Which safety standards are enforced? Who is responsible when those standards are ignored? Why are workers denied secure employment? Why are unions treated as obstacles rather than institutions of collective bargaining?
These are not merely technical questions. They concern the distribution of power within public institutions.
Reform that grants greater authority to senior management while weakening the ability of workers and citizens to challenge it does not remove politics from healthcare. It simply transfers political power upwards, away from organised workers and the public, and towards administrators and governing boards.
Amjad Mahmood’s argument concerning the replacement of retiring permanent employees with contract workers illustrates this tendency.
In managerial discourse, doctors, nurses and other hospital employees are often portrayed as barriers to efficiency. Their unions are described as disruptive, while their demands for secure employment, higher wages and better working conditions are treated as administrative inconveniences.
But workers are not external to the institution. They are the people who operate it.
Organised workers possess collective power that individual employees do not. Nurses’ unions can challenge unsafe conditions. Doctors can expose administrative failures. Employees can question staffing shortages, procurement decisions and arbitrary management practices.
This is why contractual employment cannot be treated as a neutral administrative reform.
Permanent employment offers greater protection against arbitrary dismissal. Contractual workers, by contrast, are structurally more dependent on management. The greater the insecurity of employment, the greater the authority management exercises over individual workers.
When managerial autonomy is combined with contractualisation, the result is not simply a more flexible workforce. It is a redistribution of power within the institution.
Power moves upwards. Security moves downwards.
Contractualisation weakens unions, fragments the workforce and makes collective resistance more difficult. It also creates a convenient mechanism for shifting blame onto individual workers when institutional failures occur. A contractual employee can be disciplined or dismissed, while the management structure that produced the crisis remains intact.
This is the underlying attraction of contractualisation for authoritarian management: flexibility at the top is secured through insecurity at the bottom.
Pakistan’s public institutions are not collapsing because there is too much accountability. They are failing because accountability is weak, resources are inadequate, institutions are politicised, senior appointments are frequently shaped by patronage, and administrative decisions remain insufficiently transparent.
Governments repeatedly attempt to resolve structural crises through short-term managerial interventions. However, the solution to institutional failure cannot be to insulate administrators from public scrutiny.
The greater the authority exercised by senior management over budgets, appointments, infrastructure and institutional policy, the greater its responsibility must be when things go wrong.
The hierarchy of responsibility matters. The greater the power, the greater the accountability.
Nor can every institutional crisis be blamed on junior employees. A hospital’s failures must be examined across the entire chain of command, including those who make decisions, control resources and establish institutional priorities.
The most important lesson of the PIMS tragedy lies not in the prescriptions of technocrats but in the response of ordinary citizens. People protested. They demanded answers and inquiries. They refused to accept the deaths as an unfortunate administrative accident. Their pressure compelled the government to act.
That matters because the history of public institutions is not merely a history of decline. It is also a history of struggles by workers, patients, students, citizens and communities to defend and democratise them.
Defending public healthcare does not mean defending every aspect of government bureaucracy. Public institutions can be corrupt, inefficient and undemocratic. But bureaucratic failure cannot be corrected by replacing public accountability with managerial authoritarianism.
Public hospitals need adequate and transparent funding, independent investigations into deaths and negligence, accountable senior management, transparent procurement, fair appointments and functioning complaint mechanisms. They also need secure employment, collective bargaining rights and meaningful avenues through which patients and citizens can demand answers.
Above all, they need a clear chain of responsibility.
When a child dies because an institution has failed to fulfil its obligations, somebody must be answerable.
The answer to a failing public institution is not to make its managers untouchable. It is to make them accountable. The answer to workers’ demands is not contractual insecurity, but secure employment, collective organisation and decent working conditions.
And the answer to the PIMS fire is not another layer of technocratic insulation. It is to establish what failed, identify who was responsible, hold those responsible to account and build a public health system in which neither government nor management can evade responsibility when human lives are at stake.
The next tragedy will not be prevented by managerial autonomy. It will be prevented by public control, democratic accountability and the collective power of those who work in and depend upon public institutions.