You're right. I'm not sure what checks (if any) they have in place. I guess when you apply for a renewal, they might be able to catch it there.
Another point is how much do they come here to get medical treatments? It doesn't really make sense to spend a few thousand dollars (on plane tickets) to come here for only a few days, get checked up and then leave.
They're also going to implement the per visit fee here in addition to a year fee per person. I don't think it's so much about people abusing the system as much as the bureaucrats mismanaging the money.
As far as I know the checks and balances would cost a great deal of money to implement as different governmental agencies would have to communicate with each other seamlessly and that is not going to happen anytime soon for the same reason that you mention: beureaucratic mismanagement of funds.
And I am not referring to them coming here to get medical treatments on occasion, I am speaking of them coming here to have babies and then in their retirement years, when they are most in need of medicare and prescription medicines which are then "free".
Muzna, u are just seeing this, something that happened in UK decades ago. I have mixed feelings about it, the abuse of the system is something that irks me, whether it is cases like you have noted or where tax payers have to pay more taxes to shoulder the burden of illegals who are not paying their share.
for many people though, having another citizenship is a safety net, this way if **** hits the fan back in their home country they can get out aside from being a refugee. They dont have a real desire to move out, or to move out just yet but want to have that option.
some also do it so their kids have an option to go abroad and study and not be a foreign student and be able to work and study without restrictions.
some people are very forward planning and go to a diff country to have the kids (and sometimes stiffing the hospitals) so when the kid is 18 the kid can sponsor them :) UK tried to put a hold to it because ladies were showing up about to pop a kid and over there they would just have the free hospital, get the kid a UK passport and leave. but when they started making policies that women with visible advanced pregnancies cant get in, everyone started talking about racism.
I totally understand the safety net part....and I can't blame anyone for wanting this sort of security for their children if not for themselves when they live in a volatile country like Pakistan. I also agree with the advanced education facilities that they may want to take advantage of, but then there should be a system in place that identifies how much they have paid into the social welfare/healthcare system and assigns a benefit payout in proportion with that. There needs to equity and/or accountability so that the system cannot be abused.