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Logic behind the langar
Logic behind the langar Published in The News International, October 15, 2019
The Langar Policy is one of several policies under the Ehsaas umbrella, in its Safety Net category. This policy is being implemented in the public-private partnership mode, as part of which private charities and trusts will be supported to operate langars (soup kitchens) at designated government land/premises.
The policy is predicated in the understanding that many welfare organizations in the country, already providing meals to the destitute at some scale, have capacity to upscale further significantly, if strategic support is provided by the government.
Pakistan scores very high in philanthropic giving. According to estimates, more than Rs300 billion is channelled to welfare, annually. However, up until now, the government and welfare organizations have been siloed. There has been no strategic approach to collaboration. Ehsaas aims to change that, so that the expertise and resources of reputed welfare organizations can amplify with government support.
With regard to langars, the question is: what sort of government support is needed? To this effect, three areas have been identified. The first is logistic support because currently welfare organizations often face severe resistance in setting up langars where needed most. This happens because of market dynamics and reluctance of local administration due to fear of encroachment on prime public lands. The second way in which the government can play its role is by setting safety and quality standards, and the third is by disseminating information widely.
It has therefore been decided to support selected reputable organizations that have a proven track record of providing meals at scale, and facilitate their access to government land/premises in a predicable manner. Areas where this can work best include bus stands, industrial areas, railway stations, and places where labourers tend to congregate. The langars established will be tagged in the Ehsaas App (to be launched soon). This will allow the government to create awareness about their locations, enabling millions of destitute to benefit daily. And this would be at zero cost to the government.
This is quite a departure from the standard government style of execution, where ministries want control of execution, paving the way for corruption and inefficiency.
Based on this policy approach, an agreement was signed with the Saylani Trust to open 112 langars across the country. The prototype one was opened in Islamabad; Thar will be the focus for the next set of langars. The Saylani Trust already provides over 70,000 meals a day and with government support this will be doubled. Under the agreement, the expectation is that the trust will provide healthy and nutritious meals, ensure quality of food, cleanliness in the premises; and that in each langar, hand-washing will be promoted, trans-fats will not be used in cooking, salt will be kept to a minimum, and nutrition guidelines adopted by Ehsaas will be followed.
The framework of the Ehsaas Langar Policy will also enable other reputed long-standing langar-running NGOs to partner with the government over time. We will refine the model based on implementation experience. If at any stage government funding is needed, budgetary approvals, and compliance with the Public Procurement Regulatory Authority rules will be ensured.
We have started with langars but the scope of the policy to engage the private sector in ‘welfare activities’ will later extend to other areas, guided by evidence – orphanages, protection homes, schools for the marginalized, shelters for the homeless, etc. We believe public-private synergy in a context of unprecedented giving in Pakistan can significantly scale up the work of welfare organizations, benefitting millions. Hence, an overarching Ehsaas public-private engagement policy is also under development.
Overall, the government is aware that one isolated action, policy or initiative isn’t the answer to tackling poverty, which is why the Ehsaas strategy has more than 134 mutually-reinforcing actions, designed to target different groups. Safety net initiatives are for the lowest rung – stipends for women; new policies for orphanages, disabled, shelter homes, and child protection; and Tahafuz to protect against catastrophic risks.
To help people graduate out of poverty, the policy windows include the National Poverty Graduation Initiative, financial inclusion strategy, and prize funds (first wave announced yesterday) for innovative solutions such as the new design of Thela, and garbage collecting rickshaw to create jobs are the bottom of the pyramid. Similarly, labour protection is another stream in Ehsaas, as is human capital development under which financial access to health and education are main instruments (Insaf card, need-based undergraduate scholarships, and education stipends).
As an integrated whole of government programme, Ehsaas is being executed step-by-step. Each intervention helps to reinforce the other, while we simultaneously also work on making programme improvements based on implementation insights.
To help with Ehsaas’ execution, a new ecosystem had to be built – a national survey (ongoing), digital payment system, new ministry, financing arrangements, IT systems, Delivery Unit, oversight committees, Ehsaas governance and integrity policy, and partnerships policy – a massive task in its own right.
As far as langars are concerned, we know the evidence is compelling in a context. We know that they lessen despair among the homeless. They restore dignity and self-reliance to those that will otherwise go hungry, and they contribute to grassroots activism and social cohesion with food security and nutrition aims. They also provide jobs to those involved in the operations.
The prime minister is personally committed to ensuring that no one goes to bed hungry in Pakistan – and the government will work hard to realize that vision.
The writer is the special assistant to the prime minister on poverty alleviation and social protection.
Twitter: @SaniaNishtar
The Ehsaas strategy
The Ehsaas strategy Published in The News International, September 17, 2019
The Ehsaas Strategy has been released today (pass.gov.pk/) to solicit public input, prior to its finalization. The strategy elaborates on the prime minister’s vision of a welfare state.
This is the first time that a government document has gone to government officials and the public for review at the same time, introducing a culture of openness and transparency.
Ehsaas is unique for three reasons. One, with currently 134 policies and programme elements, Ehsaas is the most ambitious umbrella initiative the Pakistan government has ever undertaken aimed at social protection and poverty alleviation.
Two, it takes a multi-sectoral and multi-stakeholder approach, recognizing the importance of the private sector, civil society and multisectoral across-government collaboration.
Three, Ehsaas is embedded in a theory of change, reflected in four pillars: action against elite capture; safety nets; livelihoods and jobs; and human capital formation with a focus on lagging areas.
Safety nets are the short-term priority within Ehsaas in view of the current fiscal austerity measures. To expand safety nets, the social protection budget has been increased and to promote integrity, the Ehsaas Governance and Integrity Policy has been prioritized. Work on the new national socioeconomic database has been fast-tracked to enable precise targeting.
The soon-to-be-launched ‘One-window Ehsaas’ will address fragmentation. To promote policy coherence and coordination, the Poverty Alleviation and Social Safety Division ‘the Ehsaas Ministry’, was established, and the previously fragmented federal social protection agencies were placed under its administrative control. BISP’s digital payment system is being revamped after a nine-year delay.
Under the new BISP programme, ‘Kifalat’, the 5.7 million BISP beneficiaries, which were previously receiving ‘cash only’ will now have access to bank accounts, mobile phones, financial literacy, digital hubs, labelled cash transfers, and graduation opportunities. The National Poverty Graduation initiative – comprising interest-free loans, asset transfers, and vocational training – and projected to impact 16.28 million individuals over four years has already been launched.
‘Tahafuz’ – Pakistan’s first shock-oriented precision safety net, will be launched by December. Ehsaas also includes welfare policies for the differently-abled, the homeless, orphans, street children, seasonal migrants, transgender, victims of child and bonded labour, daily wage workers, substance abusers, workers abroad, informal labourers, and domestic workers.
Under Ehsaas, undergraduate scholarships are on the anvil in collaboration with the HEC. A new health and nutrition conditional cash transfer programme to address stunting is in the final stages of planning, and education conditional cash transfers are being upscaled for five million children.
Beyond social protection, Ehsaas recognizes that the determinants of poverty and inequality are complex – as are the measures to address it.
Global lessons show that massive poverty reduction is the result of overall robust and sustained economic growth, when combined with economic freedoms and the will of governments to counter organized vested interest and elite capture. In Pakistan, elite capture is the root cause of poverty and is evident in water management, crop choices, land use priorities, labour laws, the taxation system, cartelization trends and nepotism patterns.
The government’s vision is driving change at various levels to address this. In its framework, Ehsaas has included objectives under Pillar I ‘Address Elite Capture’ to assist that overarching mission.
For too long, the levers of our system have been in the hands of a small group of elites. As an attempt to break that system, a constitutional amendment to move Article 38(d) from the ‘Principles of Policy’ section into the ‘Fundamental Rights’ section reflects the philosophical change within Ehsaas, while on a practical basis, Ehsaas stipulates pro-poor goals, and conflict-of-interest norms for every ministry; polices to protect resources for pro-poor initiatives; and guidelines for parliamentarians on use of development expenditure.
Ehsaas Pillar III is predicated on the understanding that human capital development is a significant contributor to the wealth of a nation in this digital age. Therefore, to catalyze action, provincial Ehsaas plans are being developed.
Ehsaas aims to create safety nets for at least ten million families, livelihood opportunities for 3.8 million people, and financial access to healthcare for ten million families. Scholarships/education incentives for five million students (50 percent girls); financial and digital inclusion for seven million individuals (90 percent women) and an enabling environment for poverty reduction by promoting mutli-sectoral partnerships and innovations. These goals will be expanded based on new partnerships. A new policy and framework of commitments will allow the private sector and the civil society to make commitments.
The strategy document outlines the government’s vision, or Ehsaas’ bedrock; the principles which drive it; the context which has shaped it; the Theory of Change, which underpins its conceptualization; and the four pillars under which its goals, policies, and programmes are organized. The strategy also outlines the manner in which 21st century approaches can be used to build a welfare state – data and technology for precision safety nets; financial and digital inclusion; human capital formation; women’s economic empowerment; value chain building for agriculture and crafts; Solutions Innovation Challenges to develop solutions for poverty; measures to address malnutrition, and multi-sectoral and multi-stakeholder approaches for solutions at scale.
Ehsaas’ premise is grounded in the importance of strengthening institutions, transparency and good governance. We realize that the limited capacity of public institutions, and governance challenges often impedes their ability to deliver. Therefore, Ehsaas is also planned with the ambition to fight through all such challenges – in that respect, implementation of the Ehsaas Governance and Integrity Policy assumes great importance.
To be fully successful, Ehsaas will need to effectively use all government levers to drive change in one direction. I strongly believe it is possible to achieve that with a constructive approach to collaboration.
The writer is the special assistant to the PM on poverty alleviation and social safety.
Twitter: @SaniaNishtar
More provinces?
More provinces? Published in The News International, May 1, 2018
Calls to create more provinces are once again resonating across Pakistan as the elections draws closer. Beyond the election rhetoric, the objective of creating more provinces in the country should be carefully deliberated to ensure that this exercise strengthens the federation and democracy rather than stirring ethno-lingual factionism, which is detrimental to good governance.
As a starting point, it must be appreciated that a province/state – in other words a sub-national and, indeed, a federating unit – has a specific status and purpose in a federation. A federation (as opposed to a unitary or confederal style of political state) is characterised by a union of partially self-governing sub-national units under a central/federal government where power-sharing between the federal and the provincial governments is constitutionally entrenched. Pakistan is one of the 27 federations in the world where the power-sharing formula between its federal and provincial governments is stipulated in its constitution. Power-sharing was altered in favour of the provinces by the 18th Amendment and the 7th National Finance Commission Award less than a decade ago.
Federations can either be as large as Russia; Brazil; and the US or as small as Saint Kitts, Nevis and Micronesia. Regardless of their size, the federating units in all federations need to have an incentive to stay in a common economic union. Contrary to popular belief, the creation of more provinces on an ethno-lingual basis could end up strengthening the federation. Allowing people to own their identity helps them become part of the mainstream, and feel less dominated and, therefore, not alienated – attributes that are vital to the viability of a federating country.
There is also a structural justification for increasing the number of provinces in our country. Pakistan has a unique situation as one of its provinces (Punjab) is larger than the sum of all others combined in terms of population size. There are difficulties inherent to the functioning of a federation when this is the case. However, we need to be mindful of the objective here. While increasing the number of provinces could potentially strengthen a multi-lingual/multi-ethnic federation, if apolitically and effectively managed, it cannot ensure improvement in the performance of governments until it is coupled with appropriate governance reforms and systemic safeguards against corruption.
To enhance the government’s performance and its capacity to govern, we must institutionalise checks and balances, and rule-based control on how the government functions and root out arbitrariness; politicisation; and bureaucratic political allegiances.
A culture of evidence-based decision-making; accountability; transparency; respect for merit; integrity; ethical conduct; and conflict of interest safeguards are critical to any meaningful attempt aimed at improving the performance of the government. The creation of more provinces will do little for the government’s effectiveness and its ability to deliver if these attributes aren’t well-institutionalised.
The creation of more provinces should also be viewed in the context of the federal-provincial relationships in the post-18th Amendment context. Eight years on, there are still countless unresolved matters; elements of mistrust; and tenuous relationships. This was also evidenced recently in the impasse during the meeting of the Council of Common Interests in relation to the federal-provincial differences over development budgets. With such unresolved matters and the lack of evidence to inform the next steps, culling out more provinces is unlikely to be effective.
In terms of the way forward, it would be important to plan incrementally. First, there is need to draw on evidence to ascertain the impact of the 18th Amendment on provincial governance and federal-provincial interface-functioning. Problems highlighted through this exercise need to be resolved as a matter of priority. A plan for a prototype model of ideal provincial and district functioning can then be drawn up in an evidence-based manner. It is critical for such a model to be grounded in a rationalised approach to recurrent fiscal implications, with cost-effectiveness as its yardstick and capacity-building inherent to its framework. This would also be an opportunity to usher in a digital transformation of the government with appropriate incentives to reshape behaviour.
Such a plan can be implemented with multi-partisan and civil society oversight. A roadmap can be developed to launch a pilot and adapt learnings. Once it is known to be effective, it can be applied on a broader scale.
This process will, however, require careful consensus-building at the national level. The implications of more provinces on administrative and fiscal matters need to be thought through carefully. Other matters, such as provincial representation in the Senate, will need political consensus. But we need to be mindful that all this will be futile if not paralleled with tangible governance reform. Increasing the number of provinces is justifiable. But we need to be mindful of the objective. Rather than a means of politicking and whipping up ethno-lingual zeal as a short-term election objective, the focus should be on using this reform as a means of strengthening the federation and improving governance. In order to achieve this, careful planning; execution; and the right motivation are needed.
Email: sania@heartfile.org
www.sanianishtar.info
Twitter: @Sanianishtar
The e-voting challenge
The e-voting challenge Published in The News International, April 13, 2018
Discussions on e-voting have re-emerged as the election draws closer and the National Database and Registration Authority (Nadra) gears up to present its plans about the three-tiered Internet Voting System for overseas Pakistanis, this week. Since I came across this subject in my capacity as a federal minister in the 2013 caretaker government, I am sharing a few insights for the planning currently underway.
E-voting for overseas Pakistanis was a subject of much discussion during the initial days of the 2013 caretaker government. The Supreme Court had issued a directive in response to a petition about the establishment of an e-voting system for overseas Pakistanis and had directed that this be expedited. Within this context, the Election Commission of Pakistan (ECP) convened a meeting of government functionaries for the process to be facilitated, which is how I and other ministers were invited to the table.
After the first meeting it became clear (at least to me) that it would be practically impossible to turn around the task in eight weeks due to time limitations. Although Nadra had developed a customised application and had demonstrated its use during presentations at the ECP, several steps were needed to be completed before the software could actually be deployed. Perhaps the most important was that it needed testing in real life situations overseas, along with quality and integrity audits, which are time consuming.
The procurement process of the hardware, on which the application was to run, was yet to be initialised. To ensure the system functions in Pakistan’s missions abroad, human resource was needed to be hired and trained, and their visas and travel arranged. The Ministry of Foreign Affairs had been pursuing permissions from the nine countries that the Supreme Court wanted this system to be functioning in. There were huge implications for Pakistan’s missions abroad in terms of physical requirements, awareness creation and compliance with local procedures. Eight weeks was nowhere near enough time to develop a foolproof system. A half-baked attempt could have been catastrophic. I volunteered to appear before the Supreme Court to explain the situation.
I narrate this story because as per the Supreme Court’s decision, e-voting for overseas Pakistanis is to be implemented this time round. I would like to flag two points in this regard. First, there are differences between the 2013 and 2018 Pakistani e-voting pilot systems. In 2013, Electronic Voting Machines (EVMs) were developed for deployment in Pakistan’s missions abroad but the project could not come to fruition. The EVMs were later used in the NA-4 by-elections in October 2017, and important lessons were learnt about their limitations. However, the system is not going to be used for the upcoming 2018 elections.
In contrast, the 2018 envisaged e-voting system allows voting from remote locations using internet, rather than at polling stations, and is being developed for overseas Pakistanis. Although each option has its own inherent challenges, one key lesson is that every new system needs adequate time and planning for conceptualisation, deployment, integrity checks, piloting and ploughing back lessons to refine the model. Other supporting factors – procedural, administrative and legislative – need to be taken into account when planning, as technology is only one cog in the process chain.
When I stepped down from my role as federal minister in 2013, I had reiterated in my Handover Papers the need for the next government to take this matter up in a timely manner and examine implications carefully. I am not privy to details as to how the matter was dealt with over the last five years, but if a demonstration is being given now, the process must be in its pre-pilot stages.
Second, there are important lessons to be learnt from the e-voting experience of Estonia. Estonia became the first country in the world to offer internet voting nationally – in local elections in 2005 and later for parliamentary elections in 2007, which is when 30 percent Estonians voted through the internet. Lessons from the Estonian example are critically important since Pakistan’s infrastructure of digital identities is somewhat similar to the Estonian model.
In 2016, an independent assessment of the procedural components of the Estonian Internet Voting System was conducted by the Cyber Studies programme of the University of Oxford. The evaluation highlighted the importance of the Estonian experience in conducting electronic elections for the last eleven years. However, while praising the system, the evaluation highlighted the unique circumstances under which Estonia has been successful and questioned the ability of the systems’ procedural controls against sophisticated cyber-attacks. The threat of cyber security is so real and pressing that in Brazil, the Brazilian Supreme Electoral Court has gone so far as organising ‘hacking competitions’ to create additional confidence in the technology. Recognising security challenges, several European countries including the UK, Germany, Netherlands and Norway cancelled e-voting systems or have decided against its large-scale use.
On balance, internet voting is feasible, which if effectively deployed, could improve accessibility for voters, especially those that are overseas and others for whom access is an issue, such as the disabled. It could also potentially save costs and time. However, in practice, the most important thing is that there needs to be a high-level of confidence in the system. Success depends on the expertise and experience of the team. There must be adequate time for the system – and not just the technology – to develop and undergo rigorous integrity checks.
Designing effective operational and procedural controls and safeguards against the risk of tampering is fundamental for the success of the programme. Estonia is grappling with this issue after two decades of having commenced on this journey. Pakistan’s institutions mandated with e-voting should ascertain where they stand in this process, and the implications a fallout would have on the credibility of the election. More broadly, they should assess how this relates to the provisions of ‘secrecy of ballot’ and ‘anonymity of voters’, which are enshrined in our constitution. As democracies around the world struggle to deal with hackers, fake news and twitter bots, would now be an optimal time to use limited resources on rolling out a lightly tested internet voting system?
Email: sania@heartfile.org
www.sanianishtar.info
Twitter: @Sanianishtar
Corrupting health
Corrupting health Published in The News International, April 7, 2018
Over half the world’s population is denied essential health services. This means that scores of communities cannot get the medicines they need, have no hospital to go to, are not being immunised and receive no advice about family planning. This is a sobering reminder on World Health Day.
To make matters worse, ill health often serves as the harbinger of poverty around the globe – with more than 800 million people spending over 10 percent of the money they have on healthcare. On a recent trip to Africa, I heard a harrowing story of a hospital where women and their newborn babies are routinely held hostage for months until families settle their bills.
Across South Asia, and here in Pakistan, we all hear stories of children being pulled out of school, cattle sold, and valuables pawned in desperate attempts to keep death at the door and food on the table. The financial hardships and unforgiving compromises households go through in order to take care of a sick relative tend to worsen when it is the breadwinner who is unwell.
There is a growing consensus that the solution to these intertwined health and economic challenges is universal health coverage (UHC), the theme of World Health Day 2018. Countries are investing in UHC to ensure that everyone has access to quality health services without having to suffer financial hardship. Far from the one-size-fits-all model, different countries use different policies to achieve UHC, depending on the unique natures of their health system, disease burden, budget and political backdrop.
With non-communicable diseases like cancer, diabetes and heart diseases on the rise, the need for UHC is becoming more pressing by the day. These diseases, once contracted, tend to stay with people for the rest of their lives, requiring the kind of sustained care and treatment that only UHC can provide.
Fortunately, the momentum around UHC is growing by the day. The World Bank has suggested that the health of a country might affect its ability to borrow, further elevating the healthcare system’s rising profile with finance ministers – typically more influential than their colleagues in health – and even heads of state. At a major forum organised by the Japanese government on the issue, Japan’s prime minister recently pledged $2.9 billion to promote UHC globally.
But even with the new packages of funding, the central barrier facing UHC is lack of money, due to strained public coffers, corruption and waste. In addition to being one of the world’s biggest sectors, healthcare is also one of the most corrupt and inefficient sector. Across the world, corrupt and collusive practices –ranging from petty theft to organised crime rackets – are well-institutionalised. The world spends nearly $7 trillion – roughly 10 percent of the global GDP – on healthcare. But $455 billion of this money is estimated to have been lost to misuse or fraud. So, at the same time that healthcare is bankrupting many of the poorest people in the world, it is increasing the bank balances of some of the richest. Corruption in the healthcare sector undermines efforts to achieve UHC by eroding financial protection efforts whilst simultaneously increasing barriers to healthcare.
It must be appreciated that UHC, anti-corruption and action against tax evasion have shared agendas. It is increasingly recognised that tax evasion does not just enable money laundering but also shrinks tax revenues, which are essential for UHC to work. It is promising that the Sustainable Development Goals include a target to “significantly reduce illicit financial flows”.
Fighting corruption requires action at many levels. Treasuries, finance ministries and dedicated anti-corruption agencies alike, must focus on prevention, detection and enforcement. Good governance needs to be better incentivised. Making financial systems more transparent will be critical to curbing health corruption. And it is not just government and business that have roles to play here; civil society, the media and patients must also demand accountability. Data mining and blockchain offer some new opportunities in detecting wrongdoing and should be fully explored for the health sector.
Demanding that more money is raised and that it is better protected and used, securing the funding needed for UHC is not a task for one government department alone, nor is UHC an undertaking that can fit into just one term of office.
Underpinning care for people throughout their lives, UHC is an inherently intergenerational programme that requires sustainable level of funding in the long run – in the fullest sense of the term. Countries will need to deeply engrain this commitment to UHC within the national psyche, even as governments change hands and more immediate pressing crises come to the fore.
Email: sania@heartfile.org
www.sanianishtar.info
Twitter: @Sanianishtar
The future of government
The future of government Published in The News International, March 17, 2018
Governments in countries such as Pakistan – with exploding and rapidly urbanising populations – face increasing challenges to deliver ‘good government’. In the context of scarce resources and declining trust, it is increasingly becoming difficult to ensure the key government mandates: delivery of law and order, justice, services to bridge inequalities, market competitiveness, and effective and even regulation.
Fortunately, technology provides an unprecedented opportunity to provide solutions even for low-resource settings. These opportunities have been tapped by the private sector, and have created islands of progress in the public system. The critical question is: will governments be able to harness them to bring about quantum change in their performance?
Even in Pakistan, when you seek services online, fast food chains and online taxis deliver on the objective of trackability, efficiency, transparency, and accountability. The same technological capabilities that underpin these service delivery mechanisms could, if well managed and strategically deployed, support the development of innovative public-sector digital ecosystems that are transparent, accountable and responsive.
The potential of Pakistan’s existing public-sector IT systems should be the starting point to explore potential. The National Database and Registration Authority (Nadra) provides solutions for identification. This infrastructure of digital identities is the foundation on which to plan the digital transformation of government services. The Republic of Estonia, the most advanced e-society in the world, is an example of what is possible. Estonia recently received the Government Leadership Award for moving public services into a fully digital mode and making 95 percent of government e-services available through mobile apps. Pakistan has the infrastructure to enable that. The country’s experience with e-filing of tax returns, initial experience of e-filing of FIRs, and land revenue automation as well as other similar initiatives – most notably those initiated by a provincial IT Board – can be the starting point for upscaling.
The Federal Bureau of Statistics’ Geographic Information System can be the foundation for location-enabled services. For example, it can be used to identify schools that are off population centres and crime sites in relation to where police stations sit. This can also enhance the government’s analytical ability and effectiveness.
Triangulation of big data from various sources and data exchange between the state’s information systems can yield significant gains, ranging from predicting diseases to improved tax collection.
Countries that are rapidly progressing have all opted for online single windows for business registration, and Pakistan must do likewise. Mobile payments systems, which are now fully developed, can be tapped for wholesale government-to-citizen payments – for example, pensions, where we know ghost payments are a problem.
Easily deployable technology applications such as video surveillance can monitor Basic Health Units and Schools, just as fast food chains monitor their branches and GPS location technologies can be used to checkmate absenteeism in public-service delivery. Sector specialists can outline a menu of practical applications of commonplace ICT solutions that can drive change in virtually every sector.
The government’s internal functioning also needs to benefit from technology. Tools within government such as e-office (system of moving files electronically) have existed over a decade. Its trackability features can improve transparency, rule-based control and efficiency and time-stamping could ingrain accountability. ERPs are used by most private-sector organisations; clearly, the country’s largest employer, the Government of Pakistan, could benefit through its use.
Technology helps fight corruption and entrenched rent-seeking, which is part of the reason why there are obstacles to upscaling these simple and often cost-effective solutions in our setting. But many countries are relying on technology precisely for this reason, and some have gone as far as to use it to promote integrity in political practices. The use of a mobile app to track campaign finances by the California Fair Political Practices Commission is a case in point.
But technology by itself is not the solution; its deployment in transparent ‘processes’, which hedge against abuse, is key. Hence, large-scale technology deployment works best in environments where the appetite to address corruption and intent to base decisions on evidence exists. Failing this, decision-makers find avenues to insulate process, which vest powers of discretion from getting automated.
There is also the need for a change in mindset. Here we see drones taking pictures at weddings and political rallies. But countries such as Rwanda are using drones to deliver blood products to haemorrhaging women in far-flung areas, and for humanitarian relief.
To usher in a digital transformation of government, technology must be deployed in new systems with appropriate incentives to reshape behaviours. New governance and regulatory models are needed to set standards, formulate policy and address concerns around privacy and security which could hinder adoption. Partnerships are key to draw on the expertise of various sectors.
Governments need to invest in new capacities (both human and technological), in infrastructure (such as e-service kiosks in rural locations) and in digital literacy. An assessment of digital maturity and the technologies and platforms needed, is a requirement, after which a roadmap can be developed to launch pilots, adapt learnings, then scale broadly. Provincial governments should engage in collaborative work, share lessons and prepare initiatives for nationwide scale up. The workforce needs to be realigned with this digital age, which is where the Higher Education Commission can play a key role.
We are starting from a long way back, but we must also prepare to tap the potential of breakthrough technologies, such as blockchain, artificial intelligence and robotics, which have significant potential to reshape governments’ potential further.
To ensure that Pakistan takes full advantage of new technologies to tackle some of our biggest challenges, an overarching digital government strategy is needed to accelerate rollout. Engaging citizens in helping shape this strategy will be critical to its overall implementation. As Pakistan, and indeed the world, goes through transformational changes, uptake in innovative technology is one of the government’s best assets to stay ahead of the curve.
Email: sania@heartfile.org
www.sanianishtar.info
Twitter: @Sanianishtar
The fight for women’s health
Nurses: our silent heroes Published in The News International, March 8, 2018
Over the last year, as the global movement for women’s equality and gender parity gained momentum, we saw a sea change around the world. Women have demanded their right to work safely, be paid fairly and live without fear of harassment and harm. This movement has been a long time coming. But it is only the beginning.
As women (and men) continue to advocate for change from #MeToo to #TimesUp and beyond, we must make sure that our vision includes uplifting women from all backgrounds across the world.
The fundamental building block of a girl’s life, whether in Botswana or Baltimore, is her health. Before a young girl in Pakistan can run a company or a country, she needs an equal chance at living a healthy life. Most girls never get that opportunity. That is why investing in women’s health around the world from birth to adolescence is both the right thing to do and comes with a huge economic dividend.
Fighting for women’s health equality isn’t an abstract slogan; it is the keystone of women’s equality. It also provides the most immediate opportunity to ‘press for progress’ — this year’s theme of International Women’s Day.
The Millennium Development Goals did help accelerate progress. However, there is still a lot more work to do. Every day, 830 mothers die in childbirth. Many of them literally bleed out at the roadside, unable to get to a hospital to get the services they need.
Unfortunately, women are dying from largely preventable or treatable complications. Adolescent girls are at a heightened risk of complications at birth. And yet, an estimated 16 million girls give birth every year. Many countries have failed to realise the commitments enshrined in the UN Convention on the Rights of Child, which prohibits marriage under the age of 18. Woefully, at least 214 million women are still unable to access family planning services that would allow them to control when they have children.
Ending child marriage and ensuring girls are educated has multiple benefits. Educated girls grow up with the skills and experience needed to make their own choices; get better jobs; have children later; and tend to space their pregnancies to suit their needs. They can lift themselves and their families out of poverty.
Women’s health often focuses only on their reproductive capacity. However, the biggest killers of men and women are now noncommunicable diseases (NCDs), such as cancer, diabetes as well as lung and heart disease. Two-thirds of deaths among women are caused by NCDs, violence and injuries. And yet, the myth that these killer diseases are mainly the domain of men persists despite evidence that suggests otherwise.
Overweight and obesity is the gateway disorder driving much of the NCD crisis. The near-double rates for women in their twenties and thirties are worrying since it is not just maternal undernutrition but also over-nutrition that undermines human capital development — the strongest indicator of the success of nations in this digital age. In fact, so significant is its interplay that the borrowing costs of countries are likely to be affected by their human capital rankings by 2025.
Maternal malnutrition has far-reaching consequences for human capital development. Women who are themselves stunted in childhood tend to have stunted offspring, creating an intergenerational cycle of poverty and reduced human capital. Malnutrition in the womb also increases the risk of adult obesity and NCDs. Therefore, many developing countries have a double malnutrition burden, with obesity coexisting alongside under-nutrition and stunting.
Gender differences in obesity and under-nutrition rates reflect the underlying gender inequality and socio-economic factors. Where female empowerment and workforce participation isn’t the norm, women are more likely to be obese. Gender inequality in society swings the pendulum of the nutritional status towards both excess female obesity and under-nutrition among women and children while greater gender equality resets the balance and favours human capital.
Gender inequality is not only a barrier for prosperity and economic growth, but also has a strong correlation with poor social outcomes. Addressing gender inequality is, therefore, critical for human capital development. Supporting and improving the education of girls; enabling women to access credit and land; and promoting the political rights of women along with their participation in economic life are potentially vital underlying interventions to address the human capital development challenge.
Over the last year, the global women’s movement has successfully taken on entrenched patriarchal and hierarchical systems to address these challenges. On this International Women’s Day, it is time to drive a women’s health revolution that saves lives and improves social and economic outcomes.
Helen Clark is the former prime minister of New Zealand and former administrator of UNDP. Dr Sania Nishtar is co-chair of a High-Level Global Commission on NCDs, the founder of Heartfile and a former federal minister.
Nurses: our silent heroes
Nurses: our silent heroes Published in The News International, March 01, 2018
While they are often in the background, nurses are at the heart of every national health system. They do everything, whether it involves caring for patients, administering lifesaving treatments in emergency situations, supervising health workers or ensuring that the correct information is passed between doctors and patients. Nurses are, in effect, the silent heroes of the healthcare system.
This week, a new global campaign, titled ‘Nursing Now’, was kicked off to celebrate the critical role that nurses play in delivering health services across the world. The campaign also seeks to ensure that recognition for nurses translates into leadership positions at all levels of the health decision-making system. ‘Nursing Now’ will run until the end of 2020, which is when nurses will be celebrated worldwide to commemorate the 200th anniversary of Florence Nightingale’s birth.
‘Nursing Now’ is an evidence based-campaign. It was conceptualised following a global review of nursing by the UK’s All-Party Parliamentary Group on Global Health, which concluded simply by reiterating that universal health coverage – the central pillar of the health-related Sustainable Development Goal 3 – cannot be achieved without developing the nursing sector across the globe.
It is no secret that the world’s health system is struggling to cope with old and new problems. Infectious killers like HIV, TB and malaria are still a major challenge in low- and middle-income countries. In addition, growing antibiotic resistance and the risk of a pandemic are presenting a tranche of new challenges that are threatening the progress made over the last few decades.
At the same time, every country in the world has seen a rise in noncommunicable diseases (NCD) that are largely driven by the global epidemic of obesity and other lifestyle-related risks. Cancer, diabetes as well as lung and heart diseases are now the leading killers of a vast segment of the population. This has presented new challenges along with climate change, new patterns of migration and the risk of new disease pandemics. Suitable reforms within the national health systems are needed to address the changing global burden of disease.
One of the fundamental principles for delivering quality health services for all is a solid workforce of well-trained and adequately supported community health workers, nurses and doctors. In order to ensure that the health workforce can tackle the new health challenges of the 21st century, it is estimated that nine million more nurses and midwives are needed by 2030. In Pakistan, there is a critical need to address this gap, where the current doctor-nurse ratio has been 2.5:1 for some time as opposed to the recommended 1:4.
This gap in the number of nurses isn’t the only issue that needs to be addressed. More often than not, nurses are undervalued and, therefore, unable to fulfil their desired potential. There are a variety of reasons for this. Since nursing is mainly a female-oriented profession, nurses are disadvantaged by traditional patriarchal structures. Despite their holistic understanding of the health system, nurses are often shut out of the health decision-making system owing to strict hierarchies and ingrained ideas about the role of nurses.
Investing in nurses in Pakistan and across the world will enhance their potential and improve their working conditions. Training and leadership skills can deliver the triple impact of improving healthcare, empowering women and strengthening local economies. As a trusted part of their communities, nurses are a key element of the process that can help us overcome today’s health challenges.
If they are properly deployed, valued and included in decision-making processes, nurses can play a critical role in promoting good health; identifying and preventing disease outbreaks; and providing care at the community level. When nurses are trained well and given greater scope to expand their roles, they deliver impressive results for patients. Maximising this potential will be vital to achieve the UN- approved goal for universal health coverage.
We are committed to ensuring that we don’t just recognise nurses but are also able to develop pathways of growth for them. We are keen on breaking the patriarchal and hierarchal systems that keep nurses from becoming key elements of the health decision-making system at all levels. One of us, as co-chair of UK’s All-Party Parliamentary Group on Global Health, is leading the global drive to mainstream the role of nursing in health systems. The other, as the co-chair of WHO’s Independent Global High-Level Commission on Noncommunicable Diseases, supported the idea that a nurse was included in the commission. Nurses are on the frontlines of the battle to tackle NCDs and drawing upon their skills and experience is critical as it determines how the commission will develop and give action to new policy recommendations to turn the tide against fatal diseases.
Nurses have been on the periphery of decision-making in the health system for too long. As the world’s health changes, we must ensure that nurses are leading the charge in how we restructure health systems to tackle the challenges of the 21st century.
Lord Nigel Crisp co-chairs UK’s All-Party Parliamentary Group on Global Health.
Dr Sania Nishtar is the co-chair of a High-Level Global Commission on NCDs.
The human capital agenda
The human capital agenda Published in The News International, February 21, 2018
As the country gears up for the 2018 general election, it is important to examine where and how human capital development features in party manifestoes. Human capital development is being emphasised for a specific reason.
Human capital development is not just inextricably linked to the principles of universalism and freedom, and to human rights. It is also the most significant contributor to the wealth of a nation – far more than physical or natural capital. Recent evidence shows that human capital contributes to 65 percent of the wealth of high-income countries and 40 percent of the wealth of low-income countries.
In the wake of this evidence, new studies have been launched globally to understand the link between human capital development and economic growth. Initiatives are being put in place by international financial institutions to accelerate financing in this regard. It is clear that in the digital age, an acceleration in technology requires countries to urgently invest in their people if they hope to compete in the economy of the future.
Human capital is, therefore, the single most important determinant of the long-term success of nation-states. By 2025, it is expected that the borrowing costs of countries will be dependent on their human development rankings. Human capital development makes it necessary to prioritise investment in the early years – tackling malnutrition; preschool or early education; protecting children from harm; ensuring access to quality education, skills and jobs; long-term commitment to universal health coverage; and measures for empowering women and girls.
Current global frameworks and developments can enable countries such as Pakistan to make major strides in human capital development. But governments need to adopt appropriate policies and have the capacity to plan for the future. One of the opportunities is embedded in the 2030 Sustainable Development Agenda. The Millennium Development Goals were influential in their own right. However, they did not focus on overcoming systemic weaknesses that impede progress. The Sustainable Development Goals have bridged this gap. They focus on data disaggregation, which is the first step to addressing inequalities.
Their emphasis on generating domestic revenue for financing development is a more sustainable means of supporting long-term, in-country social policy choices. They accord priority to country systems strengthening and the processes for better delivery so that the international system can focus on where it has a comparative advantage, which is how it should be.
Monitoring, accountability and good governance is at the heart of the 2030 agenda without which not much progress can be made. One of their targets focuses on reducing illicit financial flows and addressing corruption – and that too for good reason as human development, anti-corruption and action against tax-evasion have shared agendas.
There are additional opportunities embedded in the fourth industrial revolution, with its unprecedented developments in science and technology. For example, the ability of Blockchain to enable data exchange with security, integrity, provenance, transparency and control by users in a network could potentially revolutionise many sectors. There have been stunning developments in artificial intelligence (AI) and deep learning over the last 24 months. AI could potentially power any system with a predictive ability, which would be impossible to achieve otherwise. Billions of people are connected through personal devices where the combination of processing power, data portability and knowledge access converge to provide myriad potential solutions.
In this new future, technology could potentially change the course of human capital development. But in order for that to happen, technology needs to be deployed in systems with the right incentives structures. Standard setting, new regulatory systems and ethical frameworks are an imperative and human resource competencies need realignment.
Within this context, it would only be appropriate for political parties to commit to tapping new opportunities and paradigm shifts on the premise that this could have the potential to make quantum strides in human capital development. Political will, investment and a true commitment to making systemic improvements are clearly needed to achieve this. In addition, there also needs to be a substantial investment in the institutions and systems of the future. Manifestoes should signal intent in that direction.
Technologies such as AI and automation are already changing the demands for certain skills. This necessitates a major rethink about workforce realignment and the future of jobs in this new digital age. The fourth industrial revolution will result in major disruptions within the labour markets. New categories of jobs are emerging that will transform how and where people work. We need professionals with the right competencies and complex systems experts who can deploy technological innovations.
Pakistan’s demographic divided has yet to be tapped. Human capital development can undoubtedly fuel progress within the context of a globally-relevant long term-strategy. However, success must not be measured in terms of growth alone. The other important objective is to bridge inequality.
For this purpose, the honest redistributive hand of governments is needed so that the benefits of development can accrue equitably to the people. Therefore, in tandem with planning for the future, governance fixes are needed to build safeguards against organised vested interests.
Email: sania@heartfile.org
www.sanianishtar.info
The corruption imperative
Published in The News International, September 20, 2017
Road to Anti-corruption
Road to Anti-corruption
Published in The News International, October 3, 2017
Nishtar S, Gluckman P, Armstrong T. Ending childhood obesity
Nishtar S, Gluckman P, Armstrong T. Ending childhood obesity: a time for action. Lancet 2016 Jan 22. pii: S0140-6736(16)00140-9. doi: 10.1016/S0140-6736(16)00140-9.
Nishtar S. Delivering the WHO we need. BMJ, May 19, 2017
Nishtar S. Delivering the WHO we need. BMJ, May 19, 2017 http://blogs.bmj.com/bmj/2017/05/19/sania-nishtar-delivering-the-who-that-we-need/
Nishtar S. Opinion: A new deal for health. Devex May 2, 2017.
Nishtar S. Opinion: A new deal for health. Devex May 2, 2017. https://www.devex.com/news/opinion-a-new-deal-for-health-90171
Nishtar S. Open letter to WHO DG candidates
Nishtar S. Open letter to WHO DG candidates: reply from Sania Nishtar. 2017 May 20;389(10083):1978-1979. doi: 10.1016/S0140-6736(17)31254-0. Epub 2017 May 9.
Tuberculosis Oped
Ending childhood obesity: a time for action
Lancet response to letter on R&D
18th Amendment: five years on
Published in The News International on April 12, 2015:
It has been five years since enactment of the 18th Amendment to the constitution of Pakistan and four years since the end of the term of several committees that were given the mandate to iron out related implementation issues. Despite progress, major issues still lurk that negatively impact performance of the federal and provincial governments. These issues need to be addressed urgently.
Just for clarity, this comment refers only to the provincial autonomy-related covenants of the 18th Amendment and matters arising as a result of abolition of the concurrent legislative list. The comment underscores the need for an institutional arrangement to tackle post-18th Amendment issues, outlining several points.
First, the amendment has created an ‘ambiguity’ in the employment status of thousands of federal functionaries, whose services were either placed with the provinces after abolition of several federal ministries and/or transfer of respective departments from federal to the provincial level or those that were transferred to other federal ministries. These functionaries have been placed in a lower hierarchy and are not entitled to the same benefits anymore.
For the former category, one particular issue is that upon retirement, neither level of government owns them. This has created much disenchantment. Several functionaries have gone into litigation with the government, with the latter ending up spending more than what would take to settle pension dues. The impasse has also stalled hiring in these departments, with work suffering in some critical areas.
Second, it is being inferred that for some to-be-devolved institutions there are no enabling provincial laws. Although Article 270AA saved all federal laws, provinces feel that these need to be formally ‘devolved’ to the provincial level through amendments in the existing (federal) laws before provinces can exercise their ‘devolved’ powers. According to legal experts, this view is neither necessarily consistent with the underlying spirit of the 18th Amendment nor the language and tenor of Article 270AA. An impasse plagues devolution of some important institutions in this regard – for example, the Employees Old Age Benefit Institute and the Workers Welfare Fund.
Recently, the Punjab government has filed a writ petition against the federal government, which is particularly ironic since governments are now resorting to court rather than settling differences in the Council of Common Interest (CCI), which is an important and appropriate constitutional forum for resolution of such matters between the federal and provincial governments.
Third, an ambiguity has arisen regarding the mandate to regulate, especially for devolved subjects, given that Entry 6 of the Federal Legislative List, Part II confers the regulatory jurisdiction to the CCI housed at the federal level. In a recent decision, the Sindh High Court has struck down notifications issued by PSQCA (a federal body established under a federal law) prescribing standards for sugar (an agriculture produce and hence a ‘provincial subject’) on the ground that federal law could not regulate such activity which is a provincial subject. That decision is now under appeal before the Supreme Court, which it is hoped will settle the law on this subject.
Such issues earlier also arose in the context of regulation of medicines. It took the provinces two years to invoke Article 144 of the constitution (a provision which existed all along) but only after the tragic Isotab drug scandal, where more than 120 people died. However, even the constitutional validity of the federal law enacted to establish the Drug Regulatory Authority of Pakistan and its application to all provinces remains uncertain as this aspect is currently under consideration before the Supreme Court. This unnecessary and unproductive regulatory tangle is now the basis of tenuous federal-provincial relationships around higher education.
Confusion about assets and liabilities and their appropriate placement, and federal-provincial disagreements over control of some assets also loom. Furthermore, the lack of focal institutions (except in the health sector) at the federal level has created ambiguities for some donors, especially those that don’t have the capacity to engage with provinces. In any case ‘international treaties, conventions and agreements’ is a federal mandate (Entry 32, Part I of the Federal Legislative List). It is argued that the Economic Affairs Division has been tasked with all international agreements. However, whilst they have capacity to deal with contractual modalities, they are not set up for technical engagement. In the absence of technical focal points, many opportunities of international collaboration are therefore being lost.
Also, it must be recognised that after the 18th Amendment the federal government does not have the constitutional mandate, instruments or the institutions to bring provinces at par. District-wise segregation of any development indicator shows that Balochistan and certain other areas of the country are far more disadvantaged. One of the key roles of the federal government in a federation is to bring provinces at par with each other in order to create harmony.
Unfortunately, the federal government can no longer do that, unless specifically asked by a province, invoking Article 147 of the constitution through a provincial assembly resolution. The potential to innovate in the forthcoming National Finance Commission Award assumes importance in this respect. I will comment on this subsequently in these columns.
Finally, and most importantly, the federal government has a very important role to play in a federation – one that has to do with creating incentives for provinces to remain together in a common economic union. In this regard the evolving and future impact of the 18th Amendment provisions, which now vest ownership of mineral oil and natural gas jointly and equally in the related province and the federal government, need to be carefully studied. This clearly is a matter of national security.
There is an urgent need for an institutional arrangement (task force or committee) with the mandate but also the clout and capacity to flesh out options to address these problems and bring them to the CCI for definitive decisions. Without appropriate homework, merely raising issues at the CCI is not going to help. Without appropriate handling, tensions and ambiguities will continue and whatever positive developments the amendment accrued in relation to galvanising provincial ownership could be thwarted.
The writer is the president of the think tank Heartfile.
Email: sania@heartfile.org
www.sanianishtar.info
Ending childhood obesity: a multidimensional challenge
Peter Gluckman P, Nishtar S. Armstrong T. Ending childhood obesity: a multidimensional challenge. The Lancet 2015. DOI: http://dx.doi.org/10.1016/S0140-6736(15)60509-8
The drug pricing policy
Published in The News International on January 06, 2015:
The drug pricing policy is on the prime minister’s table for the final approval. Three dimensions of pricing need to be segregated: 1) Initial price setting, either of originator brands of new chemical entities (NCE) or their generic substitutes; 2) rationalisation of prices of medicines currently in the market; and 3) grant of annual price increase.
With regard to the first dimension, notwithstanding existing controversies, there is clarity in the policy direction since the prices of NCEs are to be fixed under the regional basket formula and that of generic substitutes, 30 percent less than the originator brand price. The third dimension can be debated, but from a policy stance its direction is clear as the annual price increase has been linked to the Consumer Price Index. The problem relates to the second point, where there are ambiguities and room for manoeuvrability.
First, the government’s intention, evident in the title of the policy “to purge the [drug regulatory] system of discretion”, would be seriously undermined and the policy would paradoxically end up increasing the discretionary powers of the regulator, the Drug Regulatory Authority. The reason for this is rooted in the simultaneous coexistence of price increase withdrawals and hardship policy covenants (grant of price moratorium waiver) in the same policy. The new pricing policy envisages withdrawing the 15 percent price increase, which has been in effect since 2013. This was granted initially by SRO 1002, subsequently struck down by the prime minister, and then upheld by the court when manufacturers challenged it. It is now the basis of the 15 percent price increase for the last twelve months.
For some categories of medicines (NCEs registered for longer than five years) the policy stipulates a further 30 percent price reduction. When price increase is struck down, most manufacturers will scramble to the regulator asking that they be accommodated under the hardship clause. Far from purging the system of discretion, the situation will make the regulator much stronger and fuel collusion even further.
Second, although there are price increase moratoriums and mandated price regulations for some categories, the overall impact on price of medicines is likely to be upwards, as one of the policy clauses enables generic products, which have a larger market share, to be priced the same as originator brands. Therefore, while the intent of the government may be to reduce medicine prices and purge discretion in regulation, the net effect may just be the opposite. That coupled with issues of shortages, which are highly likely as supply chain actors hold supplies, when initial price reductions take effect may create a negative fallout of the policy as soon as it is signed into effect.
Additionally, the mandated price reduction of NCEs, whilst they may still be under patent, means that there will be no incentive for the multinationals to introduce new innovative therapies; this may have implications for patient access, investment, and the overall government policy to facilitate the private sector.
It is therefore recommended that the summary sent to the prime minister by the Ministry of Health may be withdrawn for a review. The next iteration of the policy should address these distortions and make the pricing formula more transparent. In addition the policy must also mandate two other drug-pricing related measures in public interest, consumer education paralleled with price information systems.
There should also be a discussion on whose mandate it is to sign off on the drug pricing policy. Since the mandate of drug regulation was given to the federal government by the provinces through resolution under article 147 of the constitution, it may well be that the Council of Common Interests and not the cabinet is the appropriate competent approval authority. Clarity needs to be sought in this connection.
In terms of a broader reflection on price regulation, I would also like to reiterate that regulation of prices of medicines is fraught with an ironic paradox. On the one hand, ensuring affordability should be a critical goal. On the other, medicines are also a ‘product’ in a market environment, where price increase has to be considered. The government must, therefore, recognise that price moratoriums are not the only policy lever to make cheaper and quality drugs available in the market and in the public system, and that a combination of approaches are needed at several levels to achieve the affordability objective.
For example, the government can select manufacturers on the basis of quality standards and negotiate advanced market commitments and bundle products for public procurements. The government can also incentivise manufacturers to produce medicines that are inherently cheaper by allowing for price adjustments and address other constraints, such as allocating adequate raw material quotas and help with solutions for genuine manufacturing bottlenecks. For example, hydrochlorothiazide is one of the cheapest and most effective medicines for treating high blood pressure. It costs Rs20 for 30 tablets but its production has never been incentivised. Such solutions require astute policy capacity and transparency in regulatory and procurement systems.
Finally it must be appreciated that the role of the government is not restricted to drug pricing in this area; safety and quality are equally, if not more, important objectives. In this respect, the National Drug Policy and the Drug Act need a holistic overhaul. Many gaps have emerged overtime since they were introduced in 1997 and 1976 respectively – in particular, trends in technology, advertising and WTO agreements. Several of its clauses are exploitable. For example traditional medicine practised by 130,000 practitioners is outside the ambit of the law.
The DRA also needs a major governance overhaul. Decades-long lack of attention and under-resourcing of these institutions have resulted in clandestine manufacturing, a thriving black market, poor quality medicines and pervasive presence of spurious medicines. The pricing policy needs to be part of a mutually reinforcing policy agenda, which furthers public objectives in the health system, benefits consumers, creates an enabling environment for bona fide actors in the pharmaceutical industry and supply chain and creates barriers for black sheep. It is possible for all outcomes to be achieved through one policy instrument.
The writer is the president of the think tank Heartfile. Email: sania@heartfile.org
www.sanianishtar.info
The healthcare universe
Published in The News International on December 13, 2014:
Plunged in the corner of an orthopaedic ward in a hospital in Pakistan, ZU, a 19-year-old labourer struggles with pain and discomfort, his leg arched over a metal frame at 45 degrees. Two bricks hang from a cord tethered to a nail stuck deep in his lower thigh, preventing the fracture he sustained a week ago from misaligning. Every now and then he gazes at the door to see if his brother is back from the village with the money needed to fix his leg. The only goat they possessed had fetched half the amount needed to buy a surgically implantable nail, necessary to cement the bone. His brother had now gone back to the village to borrow the rest.
He wonders if his fate will be the same as that of the man at the far end of the ward, who was taken back home in a similar situation after ten days in the hospital after his family was unable to buy the surgical implant needed to fix his fracture. ZU stares at the Rs5000 he had borrowed from his employer the day the trolley ran over his leg, haunts him. He gazes at it in his palm and struggles with a decision – should he keep it for medicines, which he would need in addition to the expensive nail or should he send it home. He grapples both with emotional and physical pain.
This is not a unique story, but a usual story of financially poor patients visiting public hospitals in Pakistan. It is a dilemma millions of families in the country face; they are either forced to sell assets, relinquish basic needs, or fall into debt if they have to secure treatment for their loved ones. In the process healthcare costs become economically catastrophic. Many simply forgo healthcare.
We recall the suffering of such patients now, since December 12 was the World Universal Health Coverage Day. Pakistan’s political rhetoric heavily exploits the notion of a welfare state as a national aspiration. It must be recognised that universal health coverage is at the core of the concept of a welfare state. One of its goals is to ensure that people have financial access to healthcare and that they are protected from catastrophic health expenditures and medical impoverishment.
So how can the government ensure that people like ZU and millions like him get the help they deserve in time – and at the moment of their greatest financial need? In order to answer this question we must understand where poor people seek healthcare when they have a critical healthcare need, what is available to them and where the gap lies.
Financially disadvantaged people like ZU are likely to come to government hospitals when they fall critically ill. Their faults notwithstanding, large government hospitals are the only hope for poor people and the throngs that we see there are proof of that fact.
Once in hospital, someone like ZU does not have to pay a hospital or doctor’s fee. The major cost incurs to the patient’s family when surgical disposables, implants or expensive medicines and diagnostic tests are required. At that point, patients can either seek help from the Bait-ul-mal or the hospital itself can provide the needed medicines and surgical supplies if they have already been procured and are available on the shelf. This system of support should work well for poor patients. Why do patients like ZU suffer then?
Because in reality these systems don’t work well at all. First, hospital budgets are often not enough to procure and make readily available everything needed by patients like ZU. Demand is very high due to the high population pressure on hospitals, and in many cases, corruption and pilferage compromises the already limited resources.
Second, the Bait-ul-mal is not effective in the given context. Its funding is unpredictable, it is hostage to patronage and collusion is entrenched, as a result of which there are false inclusions and false exclusions. Only a fraction of those who apply are successful and help generally comes very late. By that time many patients have already taken a loan or sell an asset, a goat, a cow, trinkets, etc. Many are also taken away from the hospital because families cannot secure the funds.
The solutions to the financial access problem of the sort faced by ZU are therefore simple but difficult to implement. One, increase and transparency in the use of hospital budgets so that medicines and surgical supplies can all be made available on the shelf in hospitals. Second, a revival of the Bait-ul-mal, making its coverage larger, more predictable and available in all hospitals ensuring that there are no false inclusions and exclusions.
There are examples of successful pilot proogrammes where effective use of technology and cell phones has made Bait-ul-mal-like programmes transparent and responsive. These can be scaled up.
There is a long list of needed reform measures in the health sector, but at the barest minimum, it is the state’s responsibility to create effective social protection for health. If our governments can develop systems to help people like ZU, a major milestone would be achieved.
The writer is the president of the think tank Heartfile. Email: sania@heartfile.org
www.sanianishtar.info
Brainstorming a better world
Published in The News International on November 19, 2014:
For the last seven years, every November around 800 thought leaders from around the world convene in the United Arab Emirates for the World Economic Forum’s Summit on the Global Agenda. Knitted as a global knowledge network of around 80 Global Agenda Councils on a wide range of subjects, the event is widely recognised as the world’s largest brainstorming event. A handful of Pakistanis are also invited each year.
Typically every year trends with regard to challenges and opportunities of the upcoming year come under discussion and are outlined in an accompanying report, the ‘Outlook on the Global Agenda’. This year, the Outlook Report released at the event outlined 10 ‘global trends’ or ‘key challenges’ facing the world over the next 12-18 months. These challenges were compiled and ranked using the Delphi method.
The report ranked them in order of priority, but here I cluster them and reflect on their relevance to Pakistan. I will club the economic challenges, ‘deepening income inequality’ and ‘persistent jobless growth’ into one cluster. These topped the list of global concerns in the report. Both are hard outcomes to gauge economic performance against, and as such, are deeply relevant to Pakistan.
Our country has a large population of youth. With the current rate of population growth, we need around three million jobs a year. Paradoxically, however, the job market may be shrinking. Without economic opportunities, our youth is vulnerable to exploitation. Today, the roots of extremism, radicalisation and mafia activity in the country can simply be traced back to the well-established patterns of exploitation of the unemployed youth. Therefore, the economic performance of governments should be gauged not just in terms of monetary and fiscal targets but also in relation to progress on job-relevant indicators.
In the second cluster, I will group three issues in the report, all of which relate to environmental degradation: rising pollution, increased occurrence of severe weather events and increasing water stress. Here again, Pakistan epitomises serious risks. Air pollution levels are considerably high in urban areas. Particulate matter smaller than 10 micrometres (PM10) stands at 91.1 microgram/cubic meter in most major cities of Pakistan. This is way above the safe level of 15 microgram/cubic meter annually. The impact of severe weather events in Pakistan is unprecedented even by global standards. The 2010 deluge, the 2011 Sindh floods and flash floods every year since then, rainfall anomalies, and the recent drought in Thar are all manifestations of climate warming.
Pakistan’s surface water availability is projected to decline drastically – from 5260 cubic meters per capita in 1951 to 1100 by 2035. Climate warming-induced changes in the mass balance of the Karakorum glaciers have reduced the flow of water down the River Indus, which is the backbone of Pakistan’s agrarian economy. Beyond water security, water stress has manifold implications for human security – in particular food and energy security, and can compound our existing problems. We must invest in mitigation, early warning and disaster preparedness.
Climate change-triggered scarcity of water is likely to be compounded by demand pressures, in particular the country’s uncontrolled population. Water scarcity and its ensuing complications can stoke conflict at several levels such as rivalries between feudal families over availability of water for their crops, disagreements between Pakistan’s landed vs manufacturing sector elite over use of water for irrigation vs hydroelectric power generation, and tensions between the provinces over control of water resources. We see beginnings of all this even now.
Lack of leadership is another global issue outlined in the report; 86 percent of the respondents in the survey agreed that we have a leadership crisis in the world today. Seventy-eight percent of Brazilian and 83 percent of the Indian respondents regarded dishonest leadership as a serious issue. This is a no-brainer in Pakistan’s list of challenges.
In addition to challenges, the report also outlined transformational opportunities related to technology, science and innovation. ‘Science and Technology’ features low on the Government of Pakistan’s list of priorities. Absence of a long-term vision for national development and recognition of its dependence on investments in Science and Technology has been one of the core impediments. We need to revamp the government’s stewardship agency for the S&T sector and link it with long-term planning to exploit this potential.
The current backlash against globalisation and a retreat to nationalism and regionalism are two other issues flagged by the report. While the world is getting increasingly integrated economically, severing ties and political isolation create risks in an interconnected world where complex interdependences characterise relationships.
The interconnectedness factor in light of the current Ebola crisis has also underscored the importance of the health sector in the economy. Emerging and remerging infections do not need passports to cross borders. They can devastate economies and can be detrimental to human wellbeing. There is a long road ahead for Pakistan in terms of strengthening health systems. Our shortcomings in polio eradication can be exemplified manifold if Ebola were to strike.
Finally, weakening of representative democracy was also one of the top 10 global challenge trends for 2015. The report stated that “mechanisms are in place for systems to be more democratic than ever. Yet there is disconnect between citizens and the officials that represent them”. The Pakistanis at the meeting could relate to this, but on a positive note there are also some important developments in the country such as a revival of the political culture, an open media, and progress in constitutional separation of powers.
This notwithstanding, we must understand that democracy is not just about ‘majority rule’; it is also about institutional democratic practices, democratic values and individual practices of consensus-building, and that many attributes of democracy are deeply interlinked with principles of good governance. We must appreciate that democracy, as understood conventionally, may be a necessary condition for good government, but it is certainly not a sufficient one.
The writer is a member of the World Economic Forum’s Global Agenda Council since 2007.
Email: sania@heartfile.org
Ministries: a review
Published in The News International on October 31, 2014:
A special cabinet meeting has been scheduled for today (October 31) to conduct a performance review of all ministries, divisions and departments. In this context, I am offering some reflections from my tenure as federal minister in the interim government last year.
These reflections relate to the systemic constraints, which in my opinion, stand in the way of effective governance and hence hamper the government’s performance. The frame of reference is government ministries and the issues highlighted are of a long-standing systemic nature.
First, an objective assessment of performance is possible only when goals, time-bound outcome-based targets, and performance metrics have been pre-defined. None of these is the norm in ministries. Government functionaries usually do not have a clear sense of delivery with no clear terms of reference and measurable operational targets in the context of overall goals for a sector. Hence as a starting point, these need to be framed.
My second observation relates to expectations regarding the government’s performance, which matters deeply since it determines the context in which all societal actors operate. Paradoxically, I noted that governments here were simply not set up to perform. In setting up and running the government, the focus is on all attributes – elections, installing leadership, cabinet selection, and key appointments – except those that matter for its performance.
As a result, the government’s wide-ranging strategic functions, which could provide a scaffold for national progress and development, are compromised. In this regard, I found two key features missing from the performance equation – incentives and accountability.
Lack of appropriate incentives leads to underperformance. Rigidity of compensation is one aspect but perverse incentives, illustrated for example in the tendency to reward bureaucrats for furthering political allegiances, are more damaging. Additionally, there are serious gaps in performance and decision-making accountability. Functionaries are simply not answerable for performance. As a result, policies have limited grounding in evidence, priorities are determined by political expediency, the policy-action disconnects remain unaccounted and unnecessary policy vacillations, detrimental for reform, go unchecked.
Many upright government functionaries of integrity navigate this space with great difficulty. The system just does not empower them to take control fully. On the other hand, corruption, collusion and arbitrage have become deeply entrenched. In many cases these have become the system itself. Many government departments extract rents and distribute them according to well-established shadow ‘rules’, which now govern the de facto functioning of departments.
These performance distortions get compounded by human resource competency and capacity constraints. A ministry is meant to formulate policy, set strategic direction, establish enabling frameworks, exercise impartial oversight, evenly regulate, and provide a level-playing field for private actors. Where policymaking is concerned, governments are not fungible. Policymaking and public interest are their core roles, but they must have capacity to take stock of the full range of responsibilities inherent to their mandate. Competency is crucial at the leadership level to comprehend this mandate.
How is it then that the system often places a leader in a public agency without appropriate understanding of these stewardship roles? Imagine a company with a CEO who doesn’t know the job, one who doesn’t have goals to deliver on and one who is also not accountable. What simply never happens in the private sector is the norm in the public system. With policymakers unable to understand their mandate, functionaries tangled in tactical decision-making, information systems underutilised and pervasive perverse incentives, we set government up perfectly to fail.
Compounding these performance distortions is another unrecognised factor. A popular misconception is that the government is one entity, which is not the case. The government (even at one level – federal or provincial) is an archipelago of many ministries, agencies and departments, with overlapping jurisdictions and/or competing interests. There is little incentive to work together, share resources and exploit synergy. Ironically, solutions to most public sector problems lie in intersectoral action. This creates a twofold imperative.
On the one hand governments need new competencies to tap the potential within intersectoral collaboration – such as intermediary agencies. On the other hand, new instruments and incentives are needed which can enable asset allocation mapping and foster collaborative division of labour. It is within this frame that metrics for whole of government performance assessment should also be developed with clarity on the manner in which sectors contribute to overall performance.
Unfortunately, the deepest governance reform to date, the 18th Amendment to the constitution was unable to address most of the causes of government’s underperformance despite the broad-based changes it introduced in the entire state system. Some urgently needed next steps are an imperative to enhance government performance. These should focus on institutionalising rule-based control on government functioning and rooting out politicisation and arbitrariness.
Attention to merit and conflict of interest, greater transparency through electronic filing and documentation within government ministries, electronic public expenditure tracking and procurement, better oversight of discretionary powers and effective use of existing audit tools are critical entry points to reform in that regard. These initial steps standalone have inherent promise and can pave the way for tapping the country’s inherent strengths and unlocking the potential of its people.
The writer is the president of the think tank Heartfile. Email: sania@heartfile.org
www.sanianishtar.info
Privatisation imperatives
Published in The News International on August 07, 2014:
Privatisation is subject to intensely polarised political discussions, which cloud important policy imperatives that need to be appreciated. Six points are being outlined in this respect.
First, we must get the framing on privatisation right. Privatisation must not be viewed through the narrow lens of sale of state enterprise to bridge fiscal deficit. Privatisation is deeply linked to the fundamental question of the role of the state in the economy and is part of a broader economic liberalisation and deregulation agenda.
It is one of the policy choices a government can espouse to make the private sector the engine of growth with the understanding that the role of the government is to provide an enabling policy, impartial oversight, and a level playing field for market entities. When a country such as Pakistan embarks on the broader deregulation path, it has to be prepared to overhaul its own institutional competencies within government. This is a long-term agenda. Far from political polarisation, political consensus is needed to go this route so that the course can be insulated from policy vacillation.
Second, there must be clarity about what a government can and cannot privatise. Policymaking and regulation are core government functions from which it cannot divest responsibility. Running enterprise, on the other hand is not a core government role, unless there are exceptional circumstances, such as lack of incentive for the market to operate in an area or the pursuit of a strategic objective.
Other than these exceptions, enterprise should be left to the market. Pakistan has a long list of inefficient and parasitic Public Sector Enterprises that do not fall under these list of exceptions. The government therefore has two options to deal with them – either to reform governance while continuing to have state control or privatise them. Since there is no one-size-fits-all formula, decisions must be prudent and evidence-guided.
Third, a parliamentary approval should be considered for the list of entities to be privatised. The 2000 Privatization Commission Ordinance is being interpreted as a framework privatisation act. However, lessons from other countries show that legislative authorisation is usually needed to change the status of individual PSEs as well. A legislative cover can have beneficial impact with reference to transparency and policy support for privatisation, overtime.
The fourth point relates to the institutional prerequisites for privatisation. Since engagement with the private sector demands certain institutional capabilities within the government system, the government should privatise a PSE only after an appropriate regulatory framework for the privatized entity/mandate has been created. Given Pakistan’s past performance with regulatory arrangements, a massive effort needs to be put in place to step up government regulatory capacity and develop it for sectors and mandates that are to be privatised.
Also, in terms of institutional arrangements, when a government retains an influence in the PSE following privatisation or management divestment, it is critical that it creates the right accountability of state functionaries who represent the government’s interest on the board. Procedures should be in place to safeguard impartiality, especially in the face of board remuneration several times higher than monthly salaries.
The fifth point focuses on the process safeguards that are necessary for the privatisation process. As privatisation is a complex procedure and not an ordinary auction a robust and transparent process becomes critical for its success. The opponents of privatisation are often not ideologically opposed to the idea but fear that the transactions may be carried out in a non-transparent and/or unfair manner, state assets could be sold at throwaway prices, political cronies could be rewarded for allegiances, that in the process of ‘stabilising’ these enterprises state resources may be unnecessarily spent and that strategic objectives could be compromised.
Lessons from past privatisations should be brought to bear, especially where there was evidence of monopolistic trends, collusion in valuation of assets or doubt about the motivation of buyers. Privatisation vests enormous power of patronage in governments and these concerns are a real risk. Through appropriate due diligence and conflict-of-interest management in appointment of board members of the Planning Commission and the agencies to be privatised as well as evaluators and external advisors, the government can hedge against this risk.
Also, in relation to the process, due attention to job security, wages and benefits of incumbent staff become important, with the general rule being that their contractual rights should continue to be honoured after transfer of ownership. The Pakistani post-privatisation experience has been plagued by inconclusive resolution of labour issues, with the case of the PTCL pensioners being illustrative. Lessons can be drawn from that experience.
Finally, the greatest risk for the privatisation process is the lack of accountability within the state system, as a result of which public sector functionaries cannot be held accountable for their inability to safeguard state and/or public interest in privatisation deals. The current state of existing PSEs is reflective of a style of governance to which all past government regimes have contributed.
Years of poor governance, evidenced in crony appointments, recruitments without regard to competency or organisational needs, procurement collusion and lack of accountability of decision-making have landed these organisations in the current state of affairs. Privatisation must not be pursued under the same shadow of governance.
Privatisation is indeed an option for some of the entities listed in the privatisation list. It can accrue benefits to consumers, workers, investors as well as government. We need fundamental reform of governance, one that puts decision-makers’ accountability at the core of the state system before expecting to reap privatisation’s benefits towards the goal of economic reform.
The writer is the president of the think tank Heartfile. Email: sania@heartfile.org
www.sanianishtar.info
Polio at the centre
Published in The News International on July 22, 2014:
Sometimes the rationale of a policy decision becomes apparent long after the actual decision itself. The imperatives created by the polio travel conditionality will help us understand why it was critical to re-establish Pakistan’s Ministry of Health (officially named the Ministry of National Health Services, Regulations and Coordination (NHSRC) under Pakistan’s Rules of Business).
Imagine the scenario had the WHO travel conditionality, involving polio vaccination for individuals travelling out of Pakistan, come into effect before the May 2013 decision to create the Ministry of Health. There would have been mayhem at the federal level, with confusion about responsibilities since federal mandates for health were fragmented in nine institutions during Oct 2011-May 2013, the former representing the time when the 18th Amendment came into effect.
To give a background, Pakistan’s Ministry of Health was abolished in 2011 by the 18th Amendment, on the notion that there was no need for federal ministries related to subjects that had been devolved, and since health was one of the 17 subjects devolved, its ministry was abolished. What was perhaps – inadvertently – not appreciated at the time was that there existed constitutionally-mandated federal responsibilities even for ‘subjects’ that were devolved. These fell under two Federal Legislative Lists (FLL), which are part of the constitution.
FLL Part I enumerated subjects purely under the federal government’s purview, for which the competent authority is the respective ministry/cabinet. The FLL Part II enumerates subjects of the federation, for which the Council of Common Interests acts as the competent authority. Relevant to polio, FLL Part I explicitly lists health information, cross-border spread of diseases and international treaties as being under the purview of the federal government, whereas coordination falls under the purview of FLL Part II.
Lessons from the period when health institutional responsibility at the federal level was fragmented (Oct 2011 to May 2013) indicate that the problems characteristic of that time – lack of coordination, interagency turf tensions, ambiguities about responsibility, difficulty for international partners, etc – would have further exacerbated during the existing polio travel conditionality.
All countries of the world that exist as federations have federal health institutions even if health is a fully decentralised subject. The responsibility for ensuring compliance with International Health Regulations (IHR), the world’s first legally binding agreement on fight against public health emergencies of international concern, is a central/federal responsibility in all.
The polio travel conditionality has been stipulated as part of the recommendations of an emergency committee the World Health Organisation director general convened under a mandate given under IHR. As a signatory, Pakistan has obligations, which it should and is fulfilling.
By committing to roll out vaccination of outbound travellers, the government took the right decision to play its part in attempting to halt the international spread of virus. Its capacity constraints and implementation limitations notwithstanding, the Ministry of NHSRC is one port of call where all stakeholders convened to forge federal and provincial plans in this regard. With responsibility for health in nine institutions (as it was post-18th Amendment during Oct 2011 to May 2013), this would have been a nightmare.
The creation of the Ministry of NHSRC does not mean that the centre should start stepping on provincial toes and start exerting its influence in areas that are provincial prerogatives. The functions of the 2013-established Ministry of NHSRC are strictly in line with the stipulations of the legislative lists in the post-18th Amendment constitution, which it must comply with. Ensuring disease security is part of its responsibilities, which it must step up to; there are many gaps in that regard which must be overcome as a priority.
But the fulfilment of travel restrictions should not detract Pakistan from the job of polio eradication and vaccination of children. Pakistan has many big ticket impediments in that regard. In fact, taken in the broader context of state governance, polio is a window to many of our daunting challenges. Despite these, the momentum must continue. The world is too close to the end game goal and Pakistan must not be labelled as the last remaining reservoir of poliovirus transmission in the world.
The writer is the president of the think tank Heartfile.
Email: sania@heartfile.org
Health in the post-2015 agenda: three considerations in moving forward
Nishtar S. Health in the post-2015 agenda: three considerations in moving forward. Nishtar S. East Mediterr Health J. 2014 Mar 13;20(2):71-2.
Can human resources for health in the context of non-communicable disease control be a lever for health system changes?
Nishtar S and Ralston J. Can human resources for health in the context of non-communicable disease control be a lever for health system changes? Bulletin of the World Health Organization. 2013 November; 91(11):895-896. doi: 10.2471/BLT.13.118711.
Local imperatives
Published in The News International on November 07, 2013:
The Supreme Court of Pakistan instructed the provincial authorities in April 2012 to hold local government elections “without delay”. The reason was simple. The provinces had long been delaying the legislative process and the holding of local government elections.
As the order showed, the Supreme Court had enough of the excuses presented by provincial officials and ordered the Election Commission of Pakistan (ECP) to conduct elections, maintaining that this constitutional requirement needed to be met one way or another.
Subsequent to this, however, an issue emerged as the dates for the polls were set according to the statements of provincial officials, who when pressed for a date of elections, provided random dates, disregarding the electoral schedule. By doing this, the provinces ignored the ECP’s warnings that the electoral schedule should be based on legal and operational timelines for the electoral process, which includes delimitation, registration of candidates, objections, campaign, finalization of the voters list etc.
In the past, the ECP stated repeatedly that it needed certain time to conduct elections, but it never published the electoral schedule, partially because the provinces failed to create it in the law or in the regulations.
As a further response to the Supreme Court order, the Election Commission made a two-fold announcement. On the one hand, an electoral schedule for local elections in Balochistan was announced whereas on the other, the ECP admitted that the date of elections in Punjab and Sindh given by the Supreme Court was “impractical”. Even after this announcement, however, there could be problems at two levels which need to be carefully examined.
First, with respect to Balochistan, even a cursory review of the electoral schedule reveals immense challenges. The ECP has committed to register candidates on November 6-7, leaving no time to properly instruct and train Returning Officers who are yet to be appointed. The Balochistan government has not even made borders of the constituencies (wards) public yet, so the voters and candidates do not know which areas are part of their councils.
Are a few days plausible for the level of preparation that is necessary? It appears that under the current conditions, even if the electoral process doesn’t grind to a halt because of the unrealistic schedule, it will result in deeply divisive and challenged elections which could undermine trust in the ECP and the provincial authorities in an already deeply polarised and volatile environment.
Second, in the case of Punjab and Sindh, any reply to the Supreme Court without providing a clear electoral schedule could also result in random dates which could undermine elections in those provinces.
Instead of knee-jerk reactions, the ECP should approach the Supreme Court with a pragmatic solution-oriented response and present a clear, realistic electoral schedule for which it can be held accountable. A polling date in March or April 2014 appears feasible and can provide space and time for the necessary arrangements to be put in order.
When I offered to appear before the Supreme Court as a caretaker federal minister on the issue of e-voting to explain the nature of constraints, I found the Supreme Court very receptive to factual details and honest admissions. I believe that various pillars of the state need to function together and that in order to do this there is a need for effective and timely communication. Many problems in the state system arise simply because of the inability to do so. There is a similar communication gap in the case of the local government elections; and this gap needs to be bridged urgently.
There is also another long-term policy paradox, which the parliament may consider exploring once this local government election is over. Under Pakistan’s constitution, our local government system is under authority of the provinces; the provinces have the responsibility to create laws for local elections. To complete the electoral framework, in addition to the Local Government Act, the provinces must also create election rules, which are administrative regulations.
However, the responsibility to implement provincial laws and election rules is given to the federal Election Commission of Pakistan, which is an unusual setup for a federal state, where usually provincial-level election management bodies implement elections according to their respective legal framework.
Within this broader context, it is already evident from recent experience that the current setup for local government elections in Pakistan has resulted in an unclear legal framework and ambiguous hierarchy of law, which is contributing to the current problems with local elections. This needs to be addressed as we move ahead.
The writer is the president of the think tank Heartfile. Email: sania@heartfile.org
www.sanianishtar.info
The 3G test
Published in The News International on November 01, 2013:
Earlier last month, the Supreme Court directed the government to put in place the necessary institutional arrangements at the Pakistan Telecommunication Authority, in particular hiring of the three members central to the governance of this regulatory body, so that the long awaited 3G spectrum and licence auction could be expedited.
In compliance a number of steps were taken by the government. However, the premise of the public policy discourse on 3G centres on the notion that the auction will yield revenue in foreign exchange, badly needed to offset part of the budgetary deficit. 3G should not, however, be as just a revenue-raising option; it has potential for much broader impact through its correlation with economic growth and development.
As opposed to 2G technology, 3G enables better data usage and video content viewing because of the increased speed of mobile internet, not previously available to mobile-phone users. This is not a ‘good-to-have’ luxury but has important implications for economic growth, human development, and governance.
According to the World Economic Forum’s Global Information Technology Report 2013, for a given level of mobile penetration, a 10 percent increase in 3G penetration increases GDP per-capita growth by 0.15 percentage points and a doubling of mobile data use is associated with an increase in the GDP per-capita growth rate of 0.5 percentage points.
The same report also outlines the benefits of digitisation, a process which can be facilitated by 3G, and the mass adoption of which can benefit both public and private sectors. A 10 percent increase in the country’s digitisation score drives a 0.75 percent growth in its GDP per capita. Although these projections, which assume that the necessary enablers to fully reap 3G’s benefits are in place, may not strictly apply in Pakistan’s setting, they nonetheless offer instructive evidence with respect to 3G’s overall potential.
Even with the existing constraints, 3G’s capabilities, its data transfer speed-enhancing and digitisation-enabling features can facilitate both governance as well as service delivery especially when seen in context of the country’s rapidly evolving ‘mobile money’ (money) capabilities. For example, the emphasis on transparency, targeting and effectiveness in government-to-people payments, rightly being espoused by many development partners, alone can benefit millions of people.
3G technology is available in 160 countries of the world, including even the less developed neighbouring Afghanistan. However, in Pakistan its auction has been impeded by legal and governance impediments since 2007. To begin with, a seven-year moratorium on the entry of new operators, which was part of the Pakistan Telecommunication Company Limited’s privatisation agreement, was the basis of the decision not to auction the spectrum in that time frame as it would have increased competition at the time when Etisalat had just made an investment to purchase PTCL.
The moratorium lifted in March 2013 but in the run-up to that, governance issues at the Pakistan Telecommunication Authority, the agency responsible for the auction, have been the impediment. Problems existed both at the policy ‘process’ level as well its implementation.
PTA is the telecom sector regulator, and rightly so, it is at an arms-length from the sector policymaking entity, the Ministry of Information Technology (MoIT). In 2011, MoIT had issued a policy directive asking PTA to proceed with the auction but problems with policy implementation resulted in a major deadlock which ultimately paralysed governance within the organisation.
It was ironic that the regulator of the largest industry in Pakistan was completely non-functional for at least seven months. Deadlocks over appointments lurched the process from one stay order to another, as a consequence of which functionaries within PTA endured significant hardship and several policy processes including 3G auction, stood still. The delay in the 3G auction alone has incurred a massive loss to the economy in terms of opportunity.
Most recently, the incumbent government has issued a policy directive to proceed with the auction and has resolved some of the issues at PTA. However, it remains to be seen if the auction will generate the expected level of interest given the emergence of newer technologies, which are leading consumers to use wireless broadband, or ‘hot spots’, rather than mobile networks for data. This notwithstanding, transparency and conformity with stipulated rules could be the winning ingredient in this auction, relatively speaking.
There is another legal complexity in the process of the auction, which hasn’t featured well in public debate yet. According to the Telecom Deregulation Act 2004 (Act), proceeds of the 3G ‘Spectrum’ auction are meant to be channelled into the Universal Service Fund (USF), a Section 42 company, which pools 1.5 percent of the net profits of mobile cellular operators. This Act permits ‘licence fees’ to be collected by the government though.
Governance issues notwithstanding, the USF has a very important mandate – providing subsidies to telecom operators for provision of connectivity to Pakistan’s underserved and remote areas. If appropriately harnessed, this could be truly transformative for bridging the digital divide, opening avenues for mainstreaming these remote areas in the formal economy and helping deliver health and education services to the underserved.
The government has already withdrawn part of the USF’s exiting funds through an executive order; the role of the USF’s ‘autonomous’ board in this decision remains unknown. It also appears that by opting to auction the ‘spectrum licences’, the government plans to deposit the auction fees into its consolidated fund since the Act permits the licence fees to be collected by the government.
However, according to the Act, the spectrum auction money has to go to the USF and it seems logical to assume that in order to use the auction proceeds for any purpose other than the one for which the law stipulates its use, an amendment to the law would be necessary.
It will be interesting to see how parliamentary proceedings on the amendment to the law pan out since a verdict on this would be reflective of parliamentarians’ capacity, level of engagement and ability to influence decisions. It would be unfortunate to dismantle a system with strategic potential just because we have to pay for the inefficiencies of past governments and/or finance tactical interventions.
This will be a test of the robustness of parliamentary proceedings, their actual role in key decisions, their ability to appreciate the difference between strategy and tactics and their outlook towards nation-building as opposed to short-term political gains.
The writer is the president of the think tank Heartfile. Email: sania@heartfile.org
www.sanianishtar.info
Health and research in Pakistan – Authors’ reply
Bhutta ZA, Nishtar S. Health and research in Pakistan – Authors’ reply. Lancet 2013; 382(9900):1246
Butchers galore
Published in The News International on August 23, 2013:
Lying in a surgical unit of the Khyber Teaching Hospital in Peshawar is an elderly woman with half her abdominal wall practically eaten away by infection – the outcome of a surgery carried out in a district hospital, which was mismanaged in the first place and became infected later. She has several gaping openings, through which the insides of her abdomen and muscular tissue can be seen. For those who have the stomach for such sights, I have posted the picture on my website (www.heartfile.org). Surgeons in Peshawar are patiently treating her but give a guarded prognosis.
Such patients, bearing the insignia of surgical malpractices, are usual at Pakistan’s teaching hospitals all over the country. Most suffer at the hands of quacks, imposter doctors and others that are bona fide in ‘degree’ but not in ‘practice’. Although there is no dearth of these ‘doctors’ in cities, it is the rural areas that serve as havens for them. This unfortunate woman is an illustration of policy failings on the part of successive governments to tackle a long-ignored critical policy imperative – healthcare quality regulation.
To set the frame of reference, regulation is the government’s tool to impose needed constraints. In the health sector, it can be relevant to health services, medical education, human resources, food quality, medicines and related technologies. Here, the context is regulation of healthcare service delivery, where three regulatory considerations come into play – authorisation to establish facilities, output-based control of prices and ensuring compliance with quality standards. The issue being discussed here relates to the latter.
Over the last 65 years, successive governments in Pakistan have focused largely on infrastructure and programmes as far as health service delivery is concerned. There has practically been no focus on regulation in the health sector. Today, if a citizen wants to even put up a banner on a street or a kiosk on the roadside, a number of permissions need to be solicited from various government offices with necessary diligence. But when it comes to healthcare and people’s lives, anyone can open ‘shop’ anywhere and start prescribing and cutting – no form of treatment is regulated from a quality standpoint.
Different provinces have, at various points in time, developed institutional structures such as health regulatory authorities. In most cases, the emphasis has been on creating the structure, enacting legislation, and convening boards but neither with vision and strategy nor with strong implementing arrangements to enforce meaningful action. As a result, nothing is functioning effectively and most have either been fleeting arrangements or the responsible institution has, over time, significantly deviated from its mission. As a consequence, millions of Pakistanis receive healthcare they don’t need or which can cause harm. The lady’s inflicted gaping surgical wounds are one illustration of malpractice, which manifests in individual suffering.
There are other malpractices that put populations at risk. Pakistan today is called the ‘cirrhotic state’ (a form of liver failure) because decades of needle reuse by quacks has enabled viral hepatitis to flourish relentlessly. In some cases, entire populations of villages test hepatitis positive. To cite another example, misuse of antibiotics and resulting antibiotic resistance is not just leading to poor infection control and high healthcare costs, but also threatening a return to the pre-antibiotic era with implications transcending our national borders.
Promotion of quality healthcare in a health system is a demand and supply equation. Low demand is partly the result of lack of awareness about quality and entitlements and limited knowledge about the available remedies under the existing law of torts, which is evidenced by the low frequency of court claims in tort. Development of case law in this area has also been slow.
Although the Supreme Court has reiterated the need to develop this area of law – the case of Punjab Road Transport Corporation vs Zahida Afzal and others being illustrative – and has articulated the standard of care to be provided (Alia Tareen vs Aman Ullah Khan, advocate [PLD 2005 Supreme Court 99]), it has not focused on the subject through its characteristic judicial activism approach, which today is a harbinger of change in Pakistan.
On the supply side, the solution of the problem is not to create traditional regulatory authorities. We are aware that these fall prey to the command and control style of regulation, with administrative controls and enforcement of sanctions through onsite inspections – a style of regulation that is fraught with rent seeking, as is also evidenced by experiences in drug regulation.
A multi-pronged approach has to be adopted, ranging from development of standards and guidelines, capacity building to foster compliance with stated norms, and institutionalising punitive approaches where necessary, amongst other things. At the barest minimum, provincial governments should focus on promoting adherence to prescribed guidelines in public hospitals, which notwithstanding their performance constraints – both in terms of management and patient care – are the last recourse for poor patients.
Most governments focus on changes in healthcare through reform approaches for which they neither have the institutional capacity nor the policy tenure. As opposed to this, some straightforward quality promoting measures that have significant potential, especially when in partnership with professional associations, never receive attention.
The more long-term reform-relevant approaches can incrementally ingrain incentives for better quality in healthcare through peer oversight and ‘market’ harnessing regulation. However, such approaches entail complex system change and require significant policy deviation from what is currently the norm.
While perfectly plausible in Pakistan’s mixed health system, these measures require policy consistency overtime so that the needed institutional capacity can be developed. They can be successful only if insulated from policy vacillation, which is inherent to change in government. Perhaps the image of the woman can remind health sector decision-makers about the need to think on these terms, 65 years after the country’s creation.
The writer is the president of the think tank Heartfile. Email: sania@heartfile.org
www.sanianishtar.info
Policy is not a menu
Published in The News International on July 10, 2013:
As I stepped down from my role as a caretaker federal minister last month I attempted to introduce two precedents through my Handover Papers – voluntary submission to accountability and a formal process of handing over government. In one of these, I reflected on some of the challenges that have constrained the government’s ability to govern.
Twenty-one caveats have been outlined, referring to the government’s core business, its institutions and instruments of governance, the modalities of policymaking, human resource considerations and key governance attributes.
In this article I elaborate on the caveats related to the executive’s public policymaking role. The frame of reference here is domestic policy. The term public policy has been interpreted widely; beyond a set of norms embodied in the constitution, legislative acts, judicial decisions, and formally declared government policy documents, public policy can also be framed in any other policy instrument, whether regulatory or economic in nature.
Policy formulation is the government’s core ‘business’. If government is the key to the fortune of the 180 million people in this country, then effective policy and governance is the mechanism through which that potential can be unlocked. Certain prerequisites are critical in that respect – appropriate institutional capacity, policy-relevant sector knowledge, infrastructure to inform and monitor policy and the will to base decisions on evidence.
Key functionaries in policymaking roles often lack the capacity to appreciate the potential of their mandate and remain tangled in day-to-day tactical decision-making – postings, transfers, trivial administrative matters, managing attached departments, fighting turf battles and political pressures. As a result, the space for strategic planning and policy formulation is crowded out. In addition, evidence, information and monitoring systems remain fragmented and underutilised. Overcoming these constraints is a pre-requisite for honing the government’s ability to perform its core ‘business.’
A range of issues plague the current policymaking style of the government. The foremost is a tendency to formulate policy as a wish list, an inventory of all possible policy courses of action in a sector rather than select evidence-based choices framed along an envisaged pathway to change with a clear sense of how a set of chosen policies would best fit considerations of feasibility, acceptability, political suitability, and cost-effectiveness.
Policy is not a menu, it is a choice. There has to be a clear rationale for its formulation. In my Handover Papers, I have attempted to demonstrate how a set of concordant and interrelated policies across a pathway to envisaged change can have a synergistic effect. Developing a policy also does not mean that the policy will automatically start getting into effect. In many areas, I have seen implementation and ongoing programming underway in complete deviation from stated policy norms.
There needs to be accountability for conforming the course of action within ministries with laid down policies. Plans of action, benchmarks, indicators, and the means of their measurement should be clearly outlined. I found these basic pre-requisites lacking in some areas.
With the ‘policy wish list’ formulated, ministries often think their job is done. Policy formulation is just a means to an end. It is a continuous process, where information and monitoring systems are meant to give continuous feedback about the evidence of its impact to help shape policies on an ongoing basis. In terms of what a policy has to achieve, there is also a difference between outcomes – the ultimate objective – and outputs and processes as a means of achieving outcomes. This distinction is often blurred and needs to be in sharp focus.
In policymaking, the process is as – if not more – important than the outcome or the policy itself. Arbitrariness in the process leads to problems, which can result in delays and/or capture by vested interest groups. Past aberrations in several policy processes within the Ministry of Information Technology and Telecom, in particular the policy process related to the 3G licences and spectrum auction, are examples of this.
Especially when a policy regulates high-stake commercial interests, it is critical to ensure that its process is as transparent as possible. Absence of norms for the policy formulation process is a critical gap in the government of Pakistan’s policymaking system, and needs to be bridged as a priority.
Policy continuity is another important dimension. The time needed to see through a transformation in a sector is often not limited to one government’s tenure. It takes time for policy change to take root; hence, institutional memory and policy continuity become important attributes of governance. Before starting, it is critical for new governments to explore where it is necessary to build on work in the pipeline and consolidate efforts underway so as to maximise available opportunities.
The handover process also becomes important in this respect. It should be binding on policymakers to document decisions and their rationale, and to outline where and why follow-up action and policy continuity becomes relevant. More broadly, in cases where long-term consistent direction is necessary, policies need to be insulated from vacillations through multi-partisan and multi-stakeholder consensus, towards which this government should move.
Another consideration in policy formulation is evidence. Evidence-based decision-making is both a democratic value as well as an individual attribute of behaviour in public office; without it, democracy has little value. Gaps in the evidence and information infrastructure is one aspect to this effect; more constraining is limited commitment to take appropriate policy decisions based on evidence. This is compounded by limited rational accountability of the decision-making process.
Evidence generally points to the need for long-term remedial measures; however, a combination of factors – lack of institutional maturity, career structures that foster short-sightedness and therefore orientation around short-term outputs – prevent evidence-based enduring actions from taking root. One of the most important interventions that the new government can make is to foster a culture of evidence-based decision-making in the functioning of the executive.
Finally, what matters most in public policy formulation is conflict of interest. In the affairs of the state, conflict of interest matters deeply and is one of the key ethical questions in governance. Policymakers often have business relationships in sectors where they are charged with policymaking responsibilities, raising conflict of interest concerns. This must be actively regulated and managed. However, rules regulating conflict of interest are not explicitly defined. The Code of Conduct for Ministers alludes to the need for separation, but exact modalities are not defined in a binding instrument.
A focus on transparency in decision-making is one way of regulating conflict of interest. Beyond that, however, a concrete set of binding principles is needed.
Confirming the course of public policy with these attributes is something the government must strive for if it sincerely wants to make headway in improving governance in the country.
The founder is the president of the NGO Heartfile. Email: sania@heartfile.org
Ministers and accountability
Published in The News International on June 21, 2013:
Accountability and transparency are deeply misunderstood in our country. For decades, the two have been regarded as being synonymous with politically motivated anti-corruption efforts. Nothing could be further away from the truth. Transparency opens a window into the world of government operations. Accountability, on the other hand, provides a measure of how government is performing and shows the nature and underlying motivations for decisions.
Developing transparency and accountability systems builds confidence in government and presents avenues for engagement with businesses, citizens and the civil society for achieving inclusive and sustainable growth. Transparency of decision-making is also a way of regulating conflict of interest, one of the key ethical questions in governance.
I am a staunch believer in the role of transparency and accountability as central threads in governance and democracy. Hence, when I was sworn in as federal minister in the interim cabinet, I decided to voluntarily submit myself for accountability at the end of my term. But how do you do that in a system where there are virtually no mechanisms in place to facilitate it?
After exploring possible options, I decided to use my handover papers as a tool to submit myself for accountability and decision-making transparency. Specifically, I have drafted five handover papers, three addressing individually each of the three ministries in my portfolio, one focused on a specific health-related responsibility, and another on more general governance observations. The papers are available at http://sanianishtar.info
The handover papers are aimed at enhancing the efficiency and efficacy of the process of handing over government and offer a link to my successors. They are a window into the operations of the ministries. They demystify the decision-making process to the public, provide the underlying rationale for the decisions I took while in office, and are meant to be a measure of my performance. Through these I am holding myself accountable to the people, who have a right to know why and how decisions are made in public offices.
My initiative is predicated on the belief that a culture of transparent and evidence-based decision-making is necessary to reform governance in Pakistan; and that in order to make democracies deliver, the culture of integrity, transparency and openness will have to be ingrained in government institutions and processes.
Failure to institutionalise accountability or answerability is central to most of the problems Pakistan faces today – extremism, militancy, terrorism, sectarian ethnic strife, organised criminal activity, the informal economy, mammoth debt, societal polarisation, the energy crisis, widening inequalities, and poorly performing public services exist today because individuals and institutions have been deliberately inattentive to oversight and/or opted for policy directions to the detriment of desired outcomes. If we continue to regard responsibility, answerability, and account-giving, the low level of importance they have been receiving, governance will further weaken and our challenges will increase.
Unfortunately, the last parliament failed to legislate on accountability. The country has effectively been without a comprehensive accountability framework for decades. The current iteration of Bill, which has been pending with a parliamentary committee for years, has an unacceptable list of exclusions -something the new government should explore.
I hope that my handover papers’ initiative will serve as a catalyst in two areas. In addition to initiating an accountability movement, my hope is that this process will be integrated into the normal course of the handover process for future governments. Normally in any organisation, even if a secretary changes, there is a handing over process – institutional memory, work underway, and the required next steps are communicated to the successor. Ironically, the setting in which handing over matters the most – the government system – is totally bereft of any such practice.
In articulating the handover papers, I am also attempting to set precedence for government transitions, so that each outgoing government communicates strategic policy and tactical positions, to their successors, when they leave office in the interest of ensuring policy consistency.
Each of the four ministry-specific papers summarise, for my successor minister, the work that was undertaken during my term and specify outstanding matters that need to be addressed. I have also outlined my views on reform and the needed realignment within ministries.
The handover paper of the Ministry of Information Technology and Telecom (MoIT) focuses on its key mandates, policymaking and e-governance, the MoIT’s attached institutions and its relationship with the sector regulator. Matters pertaining to the closure of YouTube and PTCL pensioners, are addressed as is the interface of Information Communication Technology (ICT) with the process of elections.
On assuming office, I noticed that the MoIT faced many governance challenges, which also manifested as distortions in its attached institutions. This led me to focus on getting things back on track, an account of which and the required next steps, I have outlined.
The Ministry of Education’s handover paper focuses on sharpening the federal edge in education. An appended mandate paper outlines post-18th Amendment federal, provincial and district roles, where confusion loomed. I also developed a policy reform plan and outlined how a few selected policy initiatives can be catalysts for sustainable changes in each of the five areas, which are constitutional federal responsibilities in the education sector.
In the Ministry of Science and Technology’s handover paper, I reflected on the nature of systemic distortions, which have led to low demand for science and technology (S&T) in Pakistan and outlined five policy levers of change for reform within the S&T sector. If these are implemented in tandem, they could simultaneously link research and development R&D and the academia with the process of national development and play a transformative role in promoting a culture of entrepreneurship.
In addition to the three ministerial portfolios, I also served as the government’s focal person for health during my term. The need for this role arose since there was no position of federal minister for health – Pakistan’s Ministry of Health had been abolished in 2010. Serious problems had arisen as a result of institutional health fragmentation with federal responsibilities and institutions spread across nine divisions. I had the defined mandate of consolidating them in a division, albeit in line with the 18th Amendment.
A mandate paper was also developed to outline federal-provincial responsibilities in health, and the urgent next steps that need to be taken at the federal level, particularly in the regulatory and health information domains. Lack of attention to these has serious domestic and international repercussions.
Each of the handover papers outlines actions through which I attempted to sow the seeds of reform with suggestions for my successors. I hope they are seen as a positive signal for the public, and the international community watching, as Pakistan transitions to a new government.
It was an honour to serve the people of Pakistan and I continue to stand ready in my civil society role to do all I can to ensure that we collectively achieve our potential in the globalised world. Building and sustaining transparency and accountability systems will be imperative to how we progress as a nation and a democracy.
The writer is the president of the think tank Heartfile. Email: sania@heartfile.org
Mega misnomers
Published in The News International on February 06, 2013:
Pakistan’s national and human security challenges have never been so pervasive. A war along the northern borders and relentless insurgency threatens the writ of the state, pitting law-enforcement agencies against people. Vested-interest groups exploit and deepen existing polarisation on ethnic, sectarian, political and religious fronts, resulting in carnage. These problems have created unprecedented pressures on an economy already plagued by serious structural problems, crippling power shortages and poor governance.
Human security and state security have become inextricably linked. Our unique pattern of polarisation has become a threat to state security. Compounding all these are sequential natural disasters, which have put the lives of millions at risk. The spiralling population too is becoming an overload, and with high levels of poverty and unemployment our youth has become vulnerable to exploitation.
Pakistan today stands very low in most international rankings. In a recent report comparing Asian countries, Pakistan’s health and education indicators have hit rock-bottom. Our ranking in the UNDP’s Human Development Index is 145 out of 187 countries. We are off-track in meeting the MDGs and have been ranked among the bottom two in the World Economic Forum’s Gender Gap rankings for the last six years.
Recent education rankings based on the proportion of girls who have never been in school, place us in the bottom 10 countries. The 2011 Household Integrated Economic Survey indicates a widening income gap between the rich and the poor; the list goes on. It is not just ‘outcome’ indicators but also the ‘process-level’ indicators that do not inspire confidence. We are slipping on transparency ratings, competitiveness rankings, doing-business inter-country measures and democracy indices.
Why is this the case? What has gone wrong? Why can’t we get our act together? Although a number of factors contribute to this quagmire, it is the misuse and abuse of three attributes of state governance that is the root cause of many of the problems we face today – politics, democracy, and accountability are the most widely misunderstood words in the country.
Politics refers to matters relating to the organisation of the affairs of the state. It is also considered analogous to the process of steering a country where a government assumes the controls of a ship. If politics is the art of navigating the ship of state, then fashioning the signs by which a steersman should steer is a function of political parties. This is where the key problem lies. Political institutions have a specific role, which centres on nurturing human resource and the strategies for the purpose of organising the running of the state and its organisations.
Since politics is also about gaining control of representative institutions, it can be understood that some level of power struggle and rivalries will be inherent to its functioning. Although Pakistan is not unique in the domination of power-play in politics, it is certainly exceptional in relation to the manner in which it has become integrated with the executive’s functioning with decision-makers reaping the benefits of incumbency for re-election. Not only is this detrimental for governance, it has also eroded the capacity of political institutions with cult- and clan-based control.
The second misunderstood attribute is democracy. Democracy is not just about ‘majority rule’; it is rather an amalgamation of many attributes. It is a set of institutional arrangements or constitutional devices. By this measure, Pakistan has achieved some progress since the 18th constitutional amendment has restored the constitution to its pre-military character. But that is not enough, since democracy is also about individual and institutional behaviours, characterised by respect for separation of powers and regard for evidence in decision-making.
As a value, democracy is closely related to liberty, equality, freedom and rights. Governments should be democratic not just in an institutional but also a social sense with attention to individual liberties, human rights and social justice. We must not rattle popular vote as a measure of democracy; we also must not regard as ‘democratic’ the ‘consensus’ between political factions over decisions that are mutually beneficial and driven by the status quo. Democracy has to mainstream the voice of all, and must uphold everyone’s interest as well.
The third misnomer is ‘accountability’, which in Pakistan is considered to be synonymous with political exploitation, as illustrated by past history of accountability institutions. Accountability in state governance is quite different from that. Pakistan’s politicisation of governance, rampant graft and a blatant disregard for merit are the causes of its quagmire. Tracked back, many of these problems have their origins in a lack of mechanisms that compel accountability. As a result of limited accountability, poor governance, mismanagement, inefficiencies and malpractices have become pervasive.
The thread of each adverse outcome in Pakistan today lies in a bad decision or deliberate oversight. From the burgeoning debt burden, the spiralling fiscal deficit, the energy quagmire, poor human development to the manner in which extremism has taken root in Pakistan, a chain of individuals in public decision-making roles can be held responsible, but are hardly ever held responsible. The accountability apparatus does not have the ability to engage in politically-blind operations. If we continue to regard responsibility, answerability, blameworthiness, liability and other attributes of account-giving, low level of importance that they have been receiving, governance will further deteriorate and we will continue to spiral downwards.
But it is not just the public system which is at fault. People are also to be blamed when they collude with the tax administration and circumvent procedures, when they are complicit with regulators in allocation of subsidies, licenses, quotas and price ceilings, or when they are in cahoots with public-sector procuring agencies, or are party to institutionalised pilfering now so characteristic of public functioning. Given the strategic significance of accountability, it is ironic that it has not been a legislative priority. Several iterations of an accountability bill have been in the legislative process. Perhaps it should be the first priority of a democratic government to get such a framework in order.
Pakistan is a country with enormous potential. While some pillars of the state suffer from malaise, the society continues to show remarkable resilience. The country is amply rich in natural resources, norms, the structure of organisations and institutions, even though they do not function well. Being a large market it offers huge investment potential. What is needed is some semblance of governance, and a certain level of policy predictability and consistency. Pakistan certainly has the ability to take off if its leadership commits to upholding the right principles in politics, democracy and accountability.
The writer is the founding president of the NGO think tank, Heartfile. Email: sania@heartfile.org
Great trepidations
Published in The News International on December 29, 2012:
The brutal assassination of nine grass-roots level health workers in Pakistan, who were involved in a door-to-door immunisation campaign in an attempt to secure children from the crippling disease of polio, adds an unprecedentedly grave dimension to the ongoing carnage in Pakistan.
Pakistan’s parliament was quick in passing a unanimous resolution and there was widespread condemnation of the killings from all factions of the society – and rightly so. These incidents have deep-seated implications for the global drive to eliminate an infectious disease for a second time from the planet.
Additionally, they illustrate the nature of polarisation, mistrust and extremism that has crept into the Pakistani society, posing challenges on many fronts – beyond public health.
This tragedy comes at a time when the Independent Monitoring Board of the Global Polio Eradication Initiative had, in its November 2012 report, issued a positive note about Pakistan with regard to its efforts to curb polio.
Pakistan’s polio programme reduced cases by more than 60 percent since last year (from 154 to 64), indicating that things could turn around after the multidimensional negative trends in 2011, where environmental surveillance indicated geographically widespread transmission and domestic numbers of new polio cases kept soaring.
During the year 2011, Pakistan was also held responsible for the virus spreading beyond its borders, causing an outbreak in neighbouring western China. Additionally, it was declared the only remaining reservoir of a rare wild poliovirus type, posing a risk for reseeding Asia.
The recent wave of killings is a huge setback, placing the 2012 gains at risk. These killings have also added another level of challenges to the existing multidimensional problems for vaccination, including problems of geographical inaccessibility due to the armed insurgency in large parts of the country; refusal to vaccinate on the mistaken notion that it is forbidden by religion; population movements across the vast and porous Pak-Afghan border; abysmal state of water and sanitation; the perception that immunisation is part of a covert operation; and the 2011 commercial-interest driven smear campaign against GAVI which, despite the government’s rebuttals, helped strengthen misplaced fears about vaccination.
In fact, polio in Pakistan today is not just a public health issue, but an illustration of the problems inherent within the state and society. Pakistan’s polio eradication drive has also taken the brunt of the country’s governance challenges.
Institutionalised collusion, geared to systematic pillage at the health systems’ level and absence of an accountability law make it very difficult to insulate polio from overall inefficiencies and malpractices which plague public sector functioning. Compounding these is the 18th Amendment-led abolition of Pakistan’s Ministry of Health and the lack of readiness of some provinces.
These challenges were already overwhelming for polio eradication efforts but the recent wave of killings adds another unprecedented complexity – polio vaccination risks becoming one of the epitomes of anti-western sentiment in Pakistan. If that happens, the global gains in polio eradication could be at risk.
Much has transpired between the 1988 World Health Assembly (WHA) Resolution, which called for eradication of polio by 2012, and global events around polio eradication in 2012. During which investment of more than US$8 billion, 20 million workers and implementation in 125 countries characterises the scale of the eradication effort.
With the May 2012 WHA Resolution, labelling polio as an emergency, WHO’s Global Polio Emergency Action Plan 2012-2013, and the Endgame Strategic Plan 2013-2018 now framed, the end is in sight. But as long as a single child remains infected, children around the world are at risk.
Pakistan now has a three-fold responsibility: addressing systemic polio eradication impediments; getting vaccination back on track with appropriate security cover for more than 90,000 vaccinators; and reaching out to the masses with the right information to allay mistrust.
At a minimum this would demand the will to prioritise action, the intent and ability of political factions to work collaboratively, and the ongoing injection of resources.
The writer is the founding present of the NGO think tank, Heartfile. Email: sania@ heartfile.org
DRA: a case for hope
Published in The News International on December 05, 2012:
The bill creating a much-needed federal drug regulatory authority – Drug Regulatory Authority of Pakistan – was enacted into law recently. The World Trade Organisation (WTO) agreements have made it binding on all countries to have independent drug regulatory authorities, without which key flexibilities permissible under the Doha Declaration on Public Health cannot be availed.
On the domestic front, the 18 Amendment to the constitution omitted the entry “Drugs and medicines” along with the Concurrent Legislative List, which had earlier given provinces the mistaken notion that drug regulation could be a subnational prerogative, leading to an unnecessary year-long federal-provincial turf battle over drug regulation. It was only after 125 lives were lost in the Isotab-related drug deaths in Lahore that the matter of drug regulation veered in the right direction.
Now that the authority has been created, it is time to take stock of the safeguards that need to be built to make it effective. First, independent regulation needs robust and transparent governance or it will fall prey to vested interest groups. It is also crucial that appointments are made on merit, and to ensure technical competency. The fact that there is a fine line between the policymaking mandate and regulatory prerogatives in this law creates all the more reason for transparency in governance.
Second, with respect to potential weaknesses of the new regulatory authority, the broader policy and institutional context has to be brought to bear. The authority, no matter how well resourced, technically astute and independent can not operate in a vacuum. Its primary purpose is to provide for “effective control and enforcement of the Drug Act, 1976”, which is where there is a problem. The Drug Act has many exploitable covenants and other gaps that have emerged as a result of recent trends in technology, advertising, and WTO agreements.
Moreover, traditional medicines prescribed by over 130,000 practitioners are outside its ambit. The Yunani, Ayurvedic and Homeopathic Practitioners Act 1965, under which traditional and herbal medicine is dealt with in Pakistan, does not provide for regulating products. The Tibb-e-Unani, Ayurvedic, Homeopathic, Herbal and other Non-Allopathic Drugs Act, 2002 has been in the pipeline for over seven years now. The new act has also brought devices and biological substances in the regulatory net, an important step since that is an area where collusion and price gouging is pervasive.
Third, the institutional infrastructure upon which the Drug Regulatory Authority will be dependent for the execution of its mandate needs critical inputs to overcome existing constraints. Drug testing laboratories, which are now rightly under the regulatory authority’s wing, need a major fiscal and technical impetus. In human resource terms, the field force of drug inspectors is not only quantitatively paltry (250 inspectors to monitor over 600 manufacturing facilities and over 50,000 retail outlets), but also qualitatively weak. Graft is the norm in regulation, both at the manufacturing and retail levels.
To a certain extent, it is the grossly inadequate systems of compensation that fuel what can be labelled as ‘subsistence graft’. These systemic distortions will have to be addressed by the authority as a priority. Also, innovative means will have to be adopted for implementing and incentivising pharmacists’ training. There are around 200 pharmacists in the 50,000 retail facilities as of now; the national capacity to train pharmacists will not be able to cover the gap in the next 20 years. A cross sectional survey conducted in the third largest city showed that only 19 percent of pharmacies met licensing requirements. Only 22 percent had qualified pharmacists, 10 percent had temperature monitoring and only four percent had alternative supply of electricity for refrigerators.
A final word of caution. As the government brings the implementation arrangements of this act to fruition, they should try and separate two kinds of malfunctions which result in the creation of spurious and falsified medicines. Within this context, I would like to draw attention to a major consensus article in the British Medical Journal. The paper focuses on the question of achieving international action on falsified and substandard medicines and proposes a global treaty to address this international menace.
It also looks at a new taxonomy of medicines, one that classifies medicines into legitimate and illegitimate. The paper divides illegitimate into two further categories. One: falsified medicines – those where there has been a criminal and fraudulent intent. The second category indicates regulatory or quality failure and manifests either in unregulated or substandard medicines. To illustrate a case in point, the case of the Isotab drug disaster in Lahore was a regulatory failure of the quality assurance systems of both the manufacturer and regulator and, while not done with a criminal intent, was serious nonetheless. Overlaps notwithstanding, the paper recommends that the former category, “falsified”, should be prosecuted by the justice system not just as civil negligence or regulatory violation but as a crime.
The new Drug Regulatory Authority presents a case for hope, but if the systemic impediments and potential distortions and loopholes in the law are not addressed, it may lead to an even worse failure than what the earlier red-tape variant of drug regulation resulted in. When harmful products get access to the market not only do they hurt the economy because of the black market, and hurt bona fide businesses because of infringements on their legitimate prerogatives, they also harm and kill humans. Those that stand in the way of creating transparent regulation could well be the victims one day.
The writer is the founder and president of the NGO think tank, Heartfile.
How to achieve international action on falsified and substandard medicines
Attaran A, Barry D, Basheer S, Bate R, Benton D, Chauvin J, Garrett L, Kickbusch I, Kohler JC, Midha K, Newton PN, Nishtar S, Orhii P, McKee M. How to achieve international action on falsified and substandard medicines. BMJ. 2012 Nov 13;345:e7381. doi: 10.1136/bmj.e7381
The new wings of development
Published in The News International on November 05, 2012:
The concept of development, through which governments view social policy in environments where capitalism is the mode of social organisation, may be up for a major rethink, globally. This year, policy signals at agenda-setting global convening and major publications seem to be heralding new directions. But in each of these, the onus of responsibility is seen to be swinging more squarely towards domestic policy. Three points are being outlined to draw attention to the potential levers of change and possible insights for Pakistan.
First, there is a palpable emphasis on “investment” rather than “aid” as a strategy for development, and recognition, that development happens through “jobs”, rather than through “growth” alone. In fact, the World Development Report, 2013, has featured jobs, boldly in its monosyllable title and has opened with the statement “development happens through jobs”. Indeed, evidence confirms that one of the strongest determinants of achieving many development outcomes is per-capita income.
Ideally, governments should aim to create the conditions that catalyse investments – macroeconomic stability, rule of law, enabling legislation, facilitative regulation, and a level playing field so that businesses can be supported, thus creating jobs. But doing just that doesn’t suffice. They must also address impediments posed by market imperfections, so that jobs with the greatest development pay-offs can be created.
Barring exceptions, it is increasingly recognised that most G77 countries should utilise aid for improvements in productive assets and institutional strengthening, so that over time they are able to reduce reliance on development assistance. This vision of development places a huge onus of responsibility on governments, rather than development agencies, which is how exactly it should be.
Secondly, with the global financial and sovereign debt crises as a context, there appears to be an emphasis on accountability not just for results but also for decisions. The importance of oversight at the fiduciary and regulatory levels has become salient and the imperative to optimise the use of resources, minimise leakages from the system, and institutionalise fiscal responsibility and debt limitation has never been more compelling. There are some straightforward, but hard to deliver policy tasks, of governments in this space.
Third, as planning gets underway to develop a post-2015 development agenda – the year in which millennium development goals will (MDG) come to term, there may be additional tasks of governments, as part of the world’s new promise, the sustainable development goals. While a sustained focus on poverty and the inclusion of environment, post Rio+20, is inevitable, other aspects of sustainable development are also likely to be included. Delivery on this new wave of global promises is not a matter of vertical thinking and silo planning. Most reviews since the MDGs have consistently raised the importance of strong institutional systems as a prerequisite for delivering on vertical targets.
Partnerships are now regarded as a sine qua non of development for a whole host of reasons, amongst which harnessing of today’s burgeoning of technological and scientific innovations in a globally interconnected world, is the foremost. For example, cell phones on their own are termed as one of the most effective channels for reaching out to those at the bottom of the pyramid and provide services that help people lift out of poverty by enabling unprecedented communication, information dissemination, tracking and financial services delivery.
A powerful combination of factors is driving change in this regard in the developing world of which advances in technologies and applications and growth in coverage of mobile cellular networks is the most salient – and this is just one example.
It is therefore up to astute governments to act inter-sectorally within the state system, as well as engage the right actors both within and outside of the development space in the private sector to forge the conditions that can tackle unemployment, step up long term inclusive growth, accrue the benefits of growth equally to populations, and take quantum leaps in development and poverty eradication.
This paradigm shift necessitates a whole new set of competencies for governments in terms of stakeholder engagement, and oversight and regulation. Results can only be as governments will make them. Short-sighted and graft-ridden governments cannot remedy their own deficiencies by seeking to yoke the private sector to their own uncertain cart.
Does Pakistan have the necessary conditions for investment and the ability to create jobs with the greatest development pay-offs? Does it have the capacity to reduce dependence on aid and address the central systemic barriers, which impede delivery on vertical targets, of which polio is currently the hallmark? Does the state system have the ability to act inter-sectorally to harness the potential within partnerships and help take to scale innovations that are burgeoning outside the state system? I leave it to the readers to reflect on these questions?
The writer is the founding president of the NGO think tank, Heartfile. Email: sania@ heartfile.org
Freedom under a shadow
Published in The News International on August 15, 2012:
Great trepidations shadow Independence Day. With the country’s increasing isolation in the arena of international politics, poor state governance, and a polarised society, Pakistan survives today primarily on the resilience of its people. This is a time to reflect on where we stand in the broader global context and appreciate the nature of the imperative.
Foremost, it should be recognised that Pakistan today exists in a world where interconnectedness and interdependence is the new global order, creating opportunities but also risks. An increasingly multi-polar world with rise of the emerging market economies-two of them in our immediate neighbourhood. We now have a world where the G20 matters as much as the G8. Similarly, we also have a context where decision-making structures of the post-World War II global governance system must now accommodate new international players. Pakistan is clearly not one of them.
The country’s “geostrategic significance” should not be confused with the importance of the emerging countries, which, despite many weaknesses, have strong prospects for sustainable growth and robust institutions. On the other hand, Pakistan’s geostrategic “significance” and what it has entailed in terms of policy choices over decades have taken a huge toll-in the shape of ideological polarisation, religious extremism, militancy, terrorism, sectarian ethnic strife, separatist movements, and the rapidly fading writ of the government across large swathes of territory. Pakistan needs to come up with a policy agenda and ensure that it has the support of all stakeholders within the state system so that a peaceful role for the country can be carved out in a globalised world.
Secondly, for the last sixty years, the world has recognised GNI as the measure of national progress and for more than a decade the Millennium Development Goals (MDGs) have propelled development and poverty eradication efforts. Both these metrics may be up for a rethink, globally, particularly as the MDGs come to term in 2015. The reasons for this are evident. The world has reached unprecedented levels of technological and organisational advancement, and productivity. Yet billions go hungry each day. World poverty and economic inequalities are soaring. Population growth is becoming a challenge, especially with regard to the pressure it places on natural resources. Our planet is increasingly becoming more susceptible to environmental degradation, climatic change, natural disasters and other catastrophic events.
The world is increasingly becoming aware of the need to reduce poverty, advance social equity and ensure environmental protection on an ever more crowded planet. The sustainable development agenda, and its metric, the Sustainable Development Goals (SDGs), are therefore becoming a normative expression of public hope. Broadly, this agenda, as outlined at Rio+ 2012 comprises three pillars, economic development, social development and environmental protection. In this transformation the world is also more conscious of the need to accord attention to building safeguards and oversight, given the havoc played by collusion and unsustainable economic policies, which have led to the present economic and sovereign debt crises.
Pakistan epitomises most of the problems the world is facing. In addition to its international isolation, Pakistan is in an economic quagmire, trapped in a cycle of debt-both problems have a compounding effect. Economic inequalities are widening. Today, Pakistan ranks 145 out of 187 countries on the Human Development Index scale. Our global governance and competitiveness rankings are plummeting while graft and collusion reach new heights.
Erosion of the state’s ability to deliver and societal polarisation is evidenced by the case of Polio eradication, where the entire organisational might of the state is unable to achieve, what can be regarded as a relatively straightforward goal. The country’s population is projected to double by 2050-making Pakistan the fourth-latest nation from the current ranking of sixth. In terms of climatic change and natural disasters, Pakistan has experienced multiple setbacks in the last decade-earthquakes of 2005 and 2008, and the 2010 and 2011 floods. The country’s vulnerabilities are well highlighted in Planning Commission’s 2010 Report on Climate Change.
Also, it must be appreciated that in today’s world national security is no longer about wars, genocide and human rights abuses. Economic, information and cyber “warfare” can cripple countries; cross-border movement of diseases can buckle economies and control over shared sources of water can define sovereignty. State, economic and human security dimensions are deeply interrelated. Water and energy insecurity, as well as political and civic instability, lead to economic and food insecurity; both of these have implications for poverty and deprivation.
These, in turn, have a causal linkage with conflict and violence in a society, which negatively impacts economic and human development and creates a vicious cycle. Pakistan faces many challenges in that respect. Energy is the lifeline of economic development-conversely, our energy crisis is compounding. Water is the backbone of an agriculture-based economy-we are running into a serious crisis. Sustainable state security is dependent on human security-our unique patterns of conflict have become a threat to state security in its own right.
Pakistan must accord attention to the structural impediments that stand in the way of its ability to deal with these problems. It must define security and pursue national-security policies accordingly. Pakistan needs to aim for sustained growth and develop mechanisms to accrue benefit of growth equitably to populations. The country needs a consolidated vision for reform across several sectors, related capacity to mainstream transformational change and multi-stakeholder oversight of the process of its implementation to ensure that reform outlives administrations and is not held hostage to short-term stakes.
These broader outcomes are dependent on success at a more basic level-addressing elite capture of the state, poor governance, eroded capacity of institutions, bureaucratic paralysis, institutionalised corruption, patronage, politicisation of decision-making, tolerance to circumventing procedures, systemic manipulation, crony appointments and lack of attention to accountability and transparency. These manifestations of systemic malaise undermine prospects for improvements in Pakistan’s economic and social indicators.
More fundamentally however, Pakistan needs to be true democracy first, in order to achieve these objectives. The Arab Spring has served as a catalyst towards democracy on a global scale. Within this trend, Pakistan appears to look good on that score, as far as “popular vote” is concerned. However, democracy is not just about “majority rule.” It must also function as a set of constitutional devices, where restraints upon the elected government can be ensured, and where all the pillars of the state function without prejudice. As a value, democracy is closely related to liberty, equality, freedom and rights and, as a principle, good governance, fairness, transparency and accountability are its hallmarks. Pakistan needs a fundamental rethink around its current democratic dispensation as a starting point, if it has the will to act.
The author is the founding president of the NGO think tank Heartfile. Email: sania@heartfile.org
The drug debacle – Part II
Published in The News International on March 06, 2012:
Currently, there is just one drug quality testing laboratory in each province but most are either inoperative or lack infrastructure, equipment, or qualified competent and experienced staff. It is critical that the government invests as well as attracts investments in this area.
An appropriately structured arrangement can have public-private resonance, offering a commercially viable investment opportunity. A sustainable system can also be developed which serves a public goal by ensuring quality of medicines.
This is also a time for a deeper policy review of the problem of substandard medicines. Pakistan today ‘boasts’ of 709 pharmaceutical units but none of them are FDA-certified. A large number of manufacturing units have been set up on shoe-string budgets and are quality deficient from the outset.
Many experts are of the opinion that the deterioration in the pharmaceutical manufacturing standards, amongst other things, is the result of the former MoH’s irrational policy – also currently in effect – of linking licensing of products to having one’s own manufacturing facility. This forces every new supplier entering the market to set up their own manufacturing facility to get into the business.
In some cases, these units are name plate operations. Many never have the volumes/capacity utilization required to achieve CGMP standards. While they put in place brick and mortar, other critical ingredients are lacking – professionals with competency, robust and validated systems and periodic audit. Most units are unable to undertake the requisite investments in manufacturing equipment and infrastructure to upgrade themselves to international levels.
As a result, substandard units have burgeoned, over time. These systemic limitations have also been recognised by some factions within the local industry itself, as was evidenced by the resignation of the PPMA (Pakistan Pharmaceutical Manufacturers’ Association) acting chief, as reported in newspapers on Feb 17.
The policy of lumping together “manufacturing license” and “commercial supplier’s license” is in deviation from the Drug Act (1976) Rules, which envisage a tolling policy allowing companies to have their products manufactured at any licensed manufacturers’ premises. Use of tolling can create an incentive for manufacturers to raise their standards and processes for both manufacturing and also quality control to international levels.
The existing policy should be reviewed in light of the recent debacle. The government must lay down minimum standards for manufacturing units with WHO’s help and should stipulate a timeline for their achievement. It is in the interest of the industry to support such standards and open themselves to licences’ review, rather than resist them as was indicated in a PPMA statement, quoted in newspapers on Feb 18.
In terms of the way forward there is also the imperative to revise the Drug Act – the fourth point. The Act’s weak enforcement is the subject of much debate, but it is not fully appreciated that the law has exploitable covenants, particularly in relation to “warranty of sale”. Traditional medicines prescribed by 130,000 practitioners remain outside the law’s purview.
A draft bill on traditional medicines has been in the parliamentary review pipeline for the last 10 years without action, for no apparent valid reason. These weaknesses have opened an avenue for collusion across the entire layer of provincial drug regulation relating to distribution, pharmacy sales and storage and have encouraged back street production of counterfeit – issues outside of the scope of today’s comment.
Lastly, it must be appreciated that much would depend on the capacity and effectiveness of the new DRA. Most of the tasks outlined above and many others would fall within its remit. The DRA must be appropriately resourced as a starting point. The government has been collecting a 1 percent tax on gross income from all pharmaceutical manufacturers since the early 70s with a view to channelling funds towards a ‘research fund’. Since the latter has not materialised fully, these billions could be used as an initial input to resource DRA’s institutional building effort in these times of severe financial hardship in Pakistan.
The DRA’s governance structure should be carefully established. It would be critical to learn from past mistakes in establishing independent regulatory authorities, where controls still rest with the government and where under-resourcing and lack of appropriate accountability frameworks create space for collusion, inefficiencies and commandeering by vested interest groups.
Meticulous transparency is needed in this respect. The EMA’s recent initiative is an example of such transparency – from March 1, 2012 the EMA will start to publish information on applications for centralised marketing authorisation for human medicines that it has received for evaluation.
One of the key responsibilities of a government is to protect its citizens, and if the present government does not step up to make radical changes it will be blamed when more tragedies inevitably occur. The new DRA is a window of opportunity – by establishing it the government has taken the right first step but much more needs to be done quickly!
(Concluded)
The writer is the founding president of the NGO think tank Heartfile. Email: sania@heartfile.org
Pakistan’s deadly cocktail of substandard drugs
Pakistan’s deadly cocktail of substandard drugs. The Lancet – 5 March 2012. DOI: 10.1016/S0140-6736(12)60277-3
The drug debacle – Part I
Published in The News International on March 05, 2012:
In 1937, more than a hundred people died in the United States as a result of using a drug formulated with a toxic solvent in what came to be known as the Elixir Sulfanilamide Tragedy. The incident was a wakeup call for the then US administration and led President Roosevelt to sign the Food, Drug and Cosmetic Drug Act into Law in 1938. The new law significantly increased federal regulatory authority over drugs and mandated the creation of the US Food and Drug Regulatory Authority (FDA).
The FDA was created as a federal entity in the United States’ federal system, even though health was a state subject. Since then, the FDA has become a global reference institution and has prevented the occurrence of similar events. For example, in the late 1950s and early 1960s, when the Thalidomide horror struck in the rest of the world with more than 10,000 children in 46 countries born with limb deformities, as a result of their mothers using the drug Thalidomide, for morning sickness, the US was largely insulated as it had already refused to authorise Thalidomide for market use because of concerns about the drug’s safety.
Although the United States and Pakistan are not comparable from a capacity or a resource standpoint there are important lessons to be learnt. Eight decades on, a similar situation has occurred in Pakistan. A hundred and fifty individuals are reported to have died as a result of drug-induced fatal bone marrow suppression. Pyrimethamine-contaminated Isosorbide 5-Mononitrate (a medicine used for the treatment of heart disease) dispensed from a public sector hospital pharmacy in Punjab was identified as the culprit drug. The hospital itself has a large catchment area, so the actual number of people who may have suffered could be higher than the known deaths.
Amidst the media frenzy around the issue, speculative opinions, and reckless punitive action, clarity is needed in three respects: where does the onus of responsibility lie? What is the potential fallout? And what needs to happen next?
In terms of responsibility, it must be appreciated that this is clearly both a failure of manufacturing and control systems at the level of the manufacturer as well as regulation. This notwithstanding, its determinants are complex. Collusion was systemically pervasive all along in granting manufacturing licenses, drug registrations and monitoring of quality with inspectors complicit in fostering deliberate inattention to oversight at the manufacturing level.
It appears that the situation deteriorated further after the 18th Constitutional Amendment. When the latter abolished the Concurrent Legislative List, devolution of “drugs and medicines” was a mistake. Provinces started calling for provincial drug regulation, in complete deviation from international best practice.
There was a clear way forward to mandate the federal government and build further on the 2005 framework for the establishment of an independent Drug Regulatory Authority (DRA), but things got complicated as the “drug regulation turf” became an additional ground for the political fight between the federal government and the government of Punjab.
As a result, seven months passed since the Ministry of Health’s (MoH) abolition, and the process of creating the DRA did not come to fruition. Meanwhile, however, the provinces used a constitutional instrument to grant the federal government a temporary regulatory mandate, which is where the Drug Cell was placed after MoH’s abolition-a fact relevant to tracking the onus of responsibility. It was only in compliance with the Superior Court’s ruling earlier this month that the DRA has been established, for the time being, in theory.
The three-fold fall out of the debacle should be fully appreciated. The tragic mortality has adversely impacted both domestic as well as international confidence. Consumers and doctors are losing faith in the safety of locally produced medicines. Although it is early to assess the quantum of impact vis-à-vis exports, signs are worrying. If left unaddressed, this could render an irreparable blow to Pakistan’s local pharmaceutical industry. Many may be producing good medicines but at the moment we have no way of demonstrating that they are GMP (Good Manufacturing Practice) compliant and produce quality tested medicines.
So what needs to happen next? Four steps are being outlined here. First, there has to be a high level international independent inquiry, including experts from FDA, the European Medicines Agency (EMA), the Australian Therapeutic Good Administration (TGA) but also countries like Malaysia, Singapore and Indonesia, as well as the World Health Organization (WHO). It is critical to ascertain what really happened and place findings in the public domain.
Secondly, from now on there must be transparency in all GMP inspection reports. The WHO Prequalification site publishes all inspection reports. For example, the report from Kenya is illustrative (http://apps.who.int/ prequal/WHOPIR/WHOPIR_Universal13-16June2011.pdf). There are many others at http://apps.who.int/prequal/ in the section labeled inspections.
All locally produced products that are widely used in Pakistan should be tested and the results posted on a publicly accessible website, such as the one the Global Fund for AIDS, TB and Malaria maintains at the page Global Fund – Pharmaceutical Quality (http://www.theglobalfund.org/en/procurement/quality/pharmaceutical/) in the section labeled “pre shipment testing”. Each cell in the spreadsheet links to a Certificate of Analysis. Experts will confirm that testing does not ensure quality, but when combined with GMP inspections and regular checks, it does go a long way. Capacity has to be built in order to implement such stipulations.
(To be concluded…)
The writer is the founding president of the NGO think tank Heartfile. Email: sania@heartfile.org
Pakistan and polio
Published in The News International on November 23, 2011:
At the recent meeting of heads of Commonwealth states, Australia put polio squarely on the table with a 54 million dollar promise. This adds to the existing pledges towards the disease eradication goal, which has collectively received more resources than any other global health intervention, to date. There is one problem though and Pakistan is in the dock once more—this time as a living threat to the global goal of eradicating a disease for the second time from the face of this planet. The weight of the allegations is mighty. After 23 years of commencing the World Health Organization-led Global Polio Eradication initiative, billions of dollars in investment, mobilization of 20 million health workers and a population wide intervention in 125 countries, vaccinating more than 2 billion children, there are only four countries in the world which continue to harbor the disease. Pakistan is the only country where cases have steadily increased since 2008. The country’s progress, as labeled by the Independent Monitoring Board of the Global Polio Eradication Initiative, now lags far behind every other country in the world and there is every indication now that Pakistan will be the last remaining reservoir of Poliovirus transmission in the world. What is additionally worrying is that poliovirus has started spreading internationally from Pakistan, as was evidenced by the recent outbreak of the crippling childhood disease in the western province of China, which WHO has traced back to Pakistan.
In many ways the case of polio eradication defies the notion that political will combined with allocation of sufficient resources will tackle any problem. That is not a given. The importance of functioning systems become apparent, as failures manifest—just as in the case of the global financial crisis and more recently the middle eastern democratic movements. Pakistan has consistently accorded high priority to polio, declared it a national emergency and allocated resources at a time of severe financial crunch, when an ongoing war, a relentless insurgency and two consecutive years of unprecedented flooding had created many competing priorities for resource allocations. The weight behind the eradication drive led by WHO and supported by the international development community channeled in money despite the severely crowded out of fiscal space, internationally. This is evidenced by the recent innovative financing for polio by the Japanese government through a debt swap, the direct pledge for polio eradication in Pakistan by the Bill and Melinda Gates Foundation, and the consistent inflow from other spearheading agencies, WHO, UNICEF, CDC, USAID and Rotary International. The support to Pakistan has been unprecedented. Despite this, Pakistan, which was a global partner in eradicating Small pox in the 70s and quietly eliminated Dracunculiasis on its own later, is now becoming a global pariah, because of its inability to eradicate polio.
The dynamics underlying this are complex. There is cross border movement of nomadic populations across the vast and porous Pakistan-Afghanistan border, both sides of which are conflict-ridden. Vast swathes of Pakistan’s Federally Administered Tribal Areas, which constitute 12% of the country’s territory and adjoining provinces, are plagued by an armed insurgency, where ongoing fighting severely limits access of vaccination teams. This is compounded by the tragic disinformation about polio vaccination. Misinformed religious factions challenge the writ of the state and campaign widely against polio on the mistaken notion that vaccination is forbidden in the religion, that it impacts on fertility and that it is part of a conspiratorial design against Muslims. Such indoctrination orchestrates refusals on part of parents to vaccinate children, even when the facility is being provided by the state at their door step. Population “mindsets” and “movements” in these polio-trouble spots do account for a majority of the new cases. But to discount the contribution of other important factors would be incorrect.
The 33 districts, which are labeled as high risk for polio and those that adjoin them, also include central Punjab and Karachi, Pakistan’s coastal metropolis, where failure to vaccinate because of poor health systems functioning and poor performance of the vaccination teams has been widely recognized. Malpractices such as absenteeism in public facilities, ghost vaccination teams, well-institutionalized pilfering from the supply chain, crony managerial appointments, collusion in monitoring records and embezzlement at the field level are all well known. Concrete and commensurate action to institutionalize and compel accountability has just not been forthcoming to address these problems. These gaps in the governance of the Polio Eradication Program are an impediment to the effective translation of the National Emergency Plan for Polio Eradication into concrete action on ground and all the sensitization, awareness creation and commitment mobilization at the highest level, ultimately comes to a naught. The same is being observed during the recent outbreak of Dengue in Pakistan. Capacity of the public primary healthcare system, which anchors the field immunization process, has been deeply eroded over the decades. Lack of policy consistency across governments has not enabled successive reforms at this level to take root and the resulting ambiguities arising as a result of the de-tracking and re-tracking from the local government system, a reform introduced in 2000, is not helping either. There has been no attempt to harness the outreach of the private sector, which delivers the bulk of healthcare in the country.
These inefficiencies are not all. Other constraints are evidenced in eight hours of load shedding interrupting vaccine cold chain, volatility in fuel prices impacting mobility of vaccinators, and poor sanitation and high population density leading to diarheal diseases—still the third commonest cause of deaths in children in Pakistan—possibly interfering with vaccine absorption. Theories of vested interest at the administrative level to linger on with National Immunization Days—the key instrument of polio eradication—because of the incentives linked to them, also abound.
Then there is the elephant in the room. Pakistan has recently abolished its Ministry of Health, under the 18th Constitutional Amendment, under which there has been massive devolution of responsibilities from the federal to the provincial level in Pakistan’s federating system. This has led to lack of responsibility for national actions in health, a fragmented health information architecture, and low human resource morale because of deployment uncertainty, all detrimental for the polio eradication drive.
The systemic malaise, which affects vaccination is evident not just in polio but also more generally with 47% children fully vaccinated, after 17 years of a relatively well funded program rolling. Polio is, therefore, also an insight into the country’s institutional capacity and the ability of its systems to deliver on programmatic endpoints. This is unacceptable and may come to haunt us in the event of an outbreak of an emerging or reemerging infection, which may be lurking in our neighboring region to the east.
Pakistan needs to put its entire organizational shoulder to the Polio eradication wheel on an emergency basis and get actors involved that can deliver in emergencies, to tackle this problem with institutionalization of accountability as a key element. So long as a single child remains infected with polio, the global goal of eradication will not be met. While at it, we must also look inwards to put in place critically needed health system reforms, which will be vital for meeting any development target in Pakistan’s mileu where social divides are widening at an alarming pace.
The author is the founder of Heartfile and the recently launched Sania Nishtar Health Fund. www.sanianishtar.info
Devolving health (Part II)
Published in The News International on September 03, 2011:
Pakistan’s Ministry of Health was abolished on the 30th of June and a number of federal health responsibilities were placed under the jurisdiction of seven other government ministries/divisions. The dynamics of this change and the questions emerging as a result thereof have been discussed in these columns on July 23. This comment presents an option for the way forward with regard to entrusting national/federal health responsibilities to appropriate institutions at the federal level. Most of these functions are linked to each other. Information, a key responsibility, has to be consolidated across streams, that in turn informs high level decisions related to national roles, in particular disease security, trade in health, federal fiscalism, external resource mobilization, each with a deep bearing on provincial and district level service delivery, health financing, human resource management and health governance.
Failure to retain national responsibilities and ensure their institutional linkages can have serious consequences. I have attempted to illustrate these by building five hypothetical scenarios.
Scenario 1, 2013: Pakistan becomes the last remaining reservoir of poliovirus transmission in the world and is jeopardizing worldwide efforts to eradicate a disease for the second time from this planet. Buffer stocks of vaccine have been depleted and the weaker provinces have not been able to put procurement systems in place. There is no concordance in national immunization days across provinces and the number of newly reported cases is burgeoning.
Scenario 2, 2012: there is an outbreak of Avian influenza in Asia and cases have been detected in Pakistan. None of the provinces take responsibility. Health information is fragmented. Emergency preparedness is under Cabinet Division, which is fire fighting on many fronts. The Central Health Establishment, responsible for health-related border security is placed under the Division for Inter-provincial coordination, which is inundated with many post-devolution responsibilities. No one owns infectious disease surveillance, all elements of which have been “devolved” with devolution of national programs. Pakistan is not compliant with International Health Regulations, 2005. If scenario 1 and 2 actually dawn, the country risks becoming a “global health pariah”.
Scenario 3, 2012: after devolution of “regulatory responsibilities” a patient form Khyber Pakhtunkhwa and service provider from Punjab lock horns in litigation in a malpractice suit. Both provinces have different standards for quality and service regulation and dilemma arises about the standards courts are to apply.
Scenario 4, 2012: an acute shortage of nurses is precipitated in Punjab as a human resource placement firm in Balochistan starts exporting nurses to the gulf countries. In a country where trade—including cross border supply of services and migration of human resource—is guaranteed by the Constitution under Article 151, cross border movement of human resource cannot be controlled.
Scenario 5, 2012: Pakistan is criticized at a multilateral forum for setting a wrong precedent for other federating systems. Some of the major development partners decide to pull out support since they cannot be responsive to four “windows” instead of one and do not want to operate in an uncertain environment. Pakistan risks losing millions of needed “health dollars” from GAVI and the Global Fund. Word limit precludes me from painting other scenarios.
Appropriately synchronized federal health structures can safeguard against such malfunctions. However, these must never encroach on provincial space in health but should strictly be confined to “national roles”. The proposal of the Health Division under a relevant ministry still stands as the best option. However, since this is perceived as being against the spirit of devolution, the next-best option for the proposed national structure is being presented. This is outlined in an illustration accessible at http://www.heartfile.org/pdf/devolutionfinalfigure.pdf
The option comprises many steps.
First, a “health structure”, which consolidates national responsibilities to the extent possible, should be delineated. The National Institute of Health’s (NIH) mandate could be expanded so that it can assume that role. The idea of an Epidemiology Division, which was mooted previously by some experts is relevant in this regard. This division, as the centerpiece and hub for health information can become an important federal institution. In the originally floated idea, the division had the mandate to deal with Integrated Disease Surveillance and Response (IDSR), its subset, the Disease Early Warning System (DEWS), the Epidemic Investigation Cell (EIC), and the Field Epidemiology and Laboratory Training Program (FELTP), all critical for ensuring disease security. In the post devolution situation, its mandate can be broadened so that it also assumes the broader responsibility for health information and engages in collating, consolidating and analyzing information and relaying it to the appropriate decision-making level. In this role it would then also be linked to the Federal Bureau of Statistics, which houses the National Health Accounts Cell and conducts the PDS and PSLM surveys, all relevant for health sector planning. In addition institutional linkages would also have to be established with the National Institute of Population Studies, the Pakistan Medical Research Council and the District Health Information System (DHIS) and where relevant its precursor, the Health Management and Information System.
Devolution of national public health programs is an opportunity to integrate silo surveillance systems, which can either be combined in the IDSR or the DHIS. For example, EPI’s case-based surveillance, its sentinel surveillance sites for Bacterial Meningitis and Rotavirus, and its Measles case-based surveillance, can be combined in IDRS for notifiable diseases, or its sub-set, DEWS. Many aspects of routine EPI surveillance such as immunization coverage, stock position and monthly reporting can be integrated with DHIS, as can the management information components of all other programs.
Secondly, a convening entity—for example, a board—for high-level policy relevant to national roles in areas related to disease security, trade in health, federal fiscalism, external resource mobilization, and inter-provincial coordination should be formed and can be entrusted with advisory, technical support and oversight functions. The convening entity should have an adequately resourced technical secretariat, which can be housed at an appropriate institutional structure. The board can have close linkages with the devolution unit in the Economic Affairs Division to which responsibility for donor linkages has been entrusted, the devolution unit in the Cabinet Division, where the government desires to place emergency preparedness, and the health unit in the Planning Commission. The enclosed figure also shows how two other institutions will continue to report to a relevant ministry, the Pakistan Medical Research Council (PMRC) and the Health Services Academy. The proposed new Drug Regulatory Authority of Pakistan has been shown reporting to the Cabinet division, since all autonomous regulatory agencies have the same reporting relationship. However technical oversight would be necessary. It has also been proposed that attention be accorded to other human resource regulatory agencies, e.g. PMRC, the Nursing Council, etc. at the same level.
In proposing this solution I have gone out of the way to accommodate sensitivities about the 18thamendment, in particular notions relating to going-against-the-spirit-of-devolution. The solution is accommodative in terms of retaining what the government has already created and builds further on that. Creation of the epidemiology division at NIH and the policy board is envisaged to cement the current post-devolution fragmentation of health to the extent possible, given current constraints.
Decision makers must commit themselves to resurrecting national roles in health. Without attention to these the spirit enshrined within devolution, provincial empowerment for enhancing their capacity and ownership to deliver services, can be seriously undermined.
Concluded
The author is the founding president of the NGO thinktank, Heartfile. sania@heartfile.org
Some misunderstood attributes
Published in The News International on August 16, 2011:
In this rapidly changing globalized and inter-connected world, some recent events are compelling us to redefine existing norms and practices. Burgeoning tensions earlier in the Middle East highlighted the need to accord higher priority to mainstreaming democracy. Recent riots in Europe underscore the salience of social reform whereas the global financial crisis necessitates greater attention to transparency within global and domestic financial and regulatory systems.
Pakistan is undergoing unprecedented transformations in this changing world. The country has opted for deep-rooted reform of its federating system through the 18th Constitutional Amendment at a time when many conventional as well as human security challenges lurk on the economic, social, and demographic fronts. The local government system is in flux, calls for new provinces are echoing loud, and remodeling of governing arrangements has become the basis of settling political disputes. Can these broader brush “reform” measures enable Pakistan to address its core systemic distortions, its key determinants of past failures and the challenges we are faced with today? Do reform attempts grounded in constitutional amendments and ordinances hold promise? Can separating territories, carving provinces, redefining government hierarchy and redrawing boundaries improve governance? Can these changes transform resource utilization and help achieve equity? Can they improve the ability of the government to accrue benefits to people, root out extremism and ensure a peaceful positive role for Pakistan in this globalized world? The purpose of this Independence Day commemorative comment is to underscore that without embracing five attributes, any reform, no matter how radical, will not work. I will attempt to draw attention to what these attributes actually mean, as some of these are terribly misunderstood.
“Democracy” is the first misunderstood term in this respect. Democracy, which is conventionally understood as ‘majority rule’ is not just about popular vote. It is a set of institutional arrangements or constitutional devices. It is about individual behaviors and practices of openness and collective deliberations, consensus-building, participation, and evidence-guided decisions in state governance, as well as governance of the political parties themselves. And it is about values of liberty, equality, freedom, and rights. The advent of majority rule is a positive step in Pakistan and democracy must be supported so that it can take root. However, alongside, it is equally important to ensure constitutional restraints upon any elected government.
The second misunderstood term is “politics”, which refers to matters relating to the organization of the affairs of the state. The instrument of politics, or political institutions have a specific role, which has to do with fostering and providing human resource and the strategies and tools for the purpose of organizing the running of the state and its organizations. Training and identifying effective leaders is one of its core functions. Since politics is about gaining control of representative institutions, some level of power play is expected. However, in our country, power struggles, internal disputes, personal rivalries, and individual and institutional divides and their interplay with ethnic and religious tensions have assumed preeminence. Consequently, our societal political culture has also been aligned on similar lines. This fundamental misconception needs to be corrected. The true essence of politics must be understood and practiced.
“Governance” is the third misconstrued attribute. The act of governing has been defined as “decisions that define expectations, grant power, or verify performance”. Related processes and systems, which involve management or leadership, are typically administered by a government, which is where we tend to place the onus of responsibility—and for good reason. Bureaucratic quality, governance capability, capacity of political authorities, policy consistency, and implementation capacity deeply impact overall growth and development, public services, and the business environment.
But other actors should also bear the responsibility for how we are governed. When tax payers scheme with tax administration, when private entities collude with regulators in allocation of subsidies, licenses, quotas and price ceilings, when commercial interests bypass procedures in order to increase market shares and when some business entities exercise influence to modify policies to suit their interests, they become parties in undermining governance. When contractors are in cahoots with procuring agencies, citizens subscribe to “sifarish” and actors pilfer resources with private sector accomplices, the role of actors outside of the government in shaping governance is additionally evident. We, therefore, must know what it takes to govern effectively, and what our respective roles are.
In the fourth place, “corruption” and the closely linked dimension of “transparency” are critically important. The former is often viewed narrowly through the lens of financial corruption, and the latter, which needs to be embraced, is poorly understood. The corrosive impact of state and elite capture, which manifests itself in a number of systemic problems, is not fully appreciated. These include misuse of authority, circumvention of procedures, manipulation of laws, nepotism and cronyism, political patronage, unfair competition, discriminatory tariffs, collusion in price and quality controls and licensing, crony privatization, granting excessive protection, turning a blind eye to regulatory collusion, and the list goes on. There is a longstanding history of attempts to address corruption through disciplinary and penalizing action in Pakistan. In contrast, very little attention has been paid to building institutions and systems that limit opportunities of collusion in the first place. Policies, which enable this, help to institutionalize transparency within the system. There have been some recent positive developments in this respect, such as media freedom, the trend towards judicial activism and the introduction of Article 19-A in the Constitution relating to Freedom of Information. However, transparency-promoting reform necessitates many other measures, which I have attempted to discuss in these columns on March 18, 2008.
Lastly, nothing overtakes “accountability” in being misunderstood. The word has been synonymous with politically motivated punitive action and chasing financial scams, which do not leave a paper trail and which our justice system finds very difficult to punish. We do not fully appreciate that accountability, or the lack thereof, is one of the core determinants of the mayhem we see all around us. There is no accountability of decisions that led the country to its present state, riddled with mammoth debt, severely crowded out fiscal space, shameful plight of its public sector enterprises, pervasive extremism, a sprawling government, a crippling energy crisis, and two others in the tow—water and food crises. The low priority accorded to accountability legislation and related institutional parameters, and the excessive list of exclusions from the ambit of accountability in the current iteration of the law, indicate that the attribute and its importance are deeply misunderstood.
Without attention to these and some other attributes such as separation of powers and attention to conflict of interest and rule of law, the premise enshrined within reforms cannot be realized. Regardless of the manner in which the provinces are carved, the government hierarchy is stacked, and decision-making prerogatives are defined, key outcomes will not be achieved. Let this be an Independence Day resolution, then. Let us try and understand what these attributes mean for governing. Learning is the first step in order to embrace change, and the need to internalize that in our country is pretty critical.
The author is the founding president of the NGO think tank, Heartfile. sania@heartfile.org
Devolving health – a way forward (Part I)
Published in The News International on July 23, 2011:
On June 28, a notification of the Government of Pakistan articulated a plan for completing the process of devolving many subjects, including health, as part of the final stages of implementing the 18th Constitutional Amendment. As a consequence, the Ministry of Health (MoH) was abolished and Pakistan became the first federal country in the world without any central coordination for health.
Whilst making this change, those at the decision making helm, however, rightly understood that there are “national” roles in health, which cannot be devolved and retained them at the “federal” level. This notwithstanding, the Commission, charged with the responsibility of implementing the amendment opted for a “cut-and-chop” formula for the MoH, housing various institutions and functions either under the command of seven other divisions—Inter-provincial coordination, Capital Administration and Development, Cabinet, Planning, Economic Affairs, States and Frontiers Affairs, and Federal Bureau of Statistics (FBS)—or merging them with other institutions.
Within this context, I will try to be as constructive as possible in this comment in offering a way forward. Let me begin by reiterating my support for the process of devolution, a broader state reform measure, in Pakistan. But let me also emphasize that such bold measures need to be preceded and followed by careful planning with respect to consensus-driven incremental transfer of responsibilities and a concerted focus on building capacity. This places a huge onus of responsibly on those leading the reform process to ensure that the premise enshrined in the process of devolution—provincial empowerment as a means of strengthening the federation and improving governance capability—is actualized.
Within this context, five sets of questions need to be considered at this stage as a step towards finding a desirable solution.
The first category of questions in centered on “strategic issues”. Where does health leadership reside and who owns health at a time when the most important institutional reform in the history of the country needs to be implemented with significant technical and negotiating skills? Who will be the national face of health in global health circles in a world, which is getting increasingly globalized? Who will represent Pakistan at the World Health Assembly next year and will that person have the appropriate mandate? At a time when Pakistan risks being the last remaining reservoir of Poliovirus transmission in the world and is jeopardizing worldwide efforts to eradicate a disease for the second time from the face of this planet, we need to accord attention to our international obligations and garner local commitment—there is long list of shortcomings.
The second set of questions relate to planning. Are there any plans to assist with this transition? Are development partners on board? Is there any mechanism to coordinate their contributions and those of other stakeholders in developing transitional plans and overseeing their implementation? Here we need to be mindful of a risk—lack of donor coordination can compound fragmentation.
The third set of questions is “provincial” in nature. Do provinces have capacity in human resource, planning and financial management and infrastructure terms, to take on these responsibilities? Have we taken into consideration the issue of asymmetry in capacity at the provincial level and possible lack of readiness on their part to take on responsibilities? Are we not inadvertently creating “centralization of power” in the provinces as a result of sudden devolution, sans checks and balances, especially when seen in the context of in-tandem scale back of the local government reform and with no tangible plans to decentralize responsibilities to the districts? What implications does this have in the context of bitter political rivalries between the central government and the largest province?
In the fourth place, restructuring at the federal level raises its own questions. What kind of issues can emerge as a result of the cut-and-chop formula? With respect to the eight divisions that are now tasked with responsibilities, which were previously within the MoH’s purview, have considerations related to capacity and mandate been given due consideration?
The cut-and-chop formula scored low on a nine-point-based assessment as a possible option for the way forward, post 18th Amendment (page 19, http://heartfile.org/pdf/HEALTH_18AM_FINAL.pdf ). However since the Implementation Commission is averse to the notion of a unified federal institutional structure for any of the devolved subjects, on the perceived notion that this is against the spirit of devolution, we are left with no choice but to offer the next best option. Possible options will be discussed towards the end of this comment.
The seven divisions have capacity constraints with respect to taking on additional functions and there are resource implications of creating the needed capacities. For example, the Economic Affairs Division (EAD) has been entrusted with “dealings and agreements with other countries and international organizations …” but beyond negotiating and signing agreements, EAD does not have the apparatus to implement agreements. WHO’s and UNICEF’s agreements are a case in point, which were previously implemented through a structure, which was housed in the international office of the MOH. There are other aspects of international dealings, which are highly technical in nature and involve Pakistan’s international commitments which do not fall in the scope of EAD’s capacities. Other aspects of international dealings have resource and procurement implications. e.g., vaccines need to be procured nationally for sometime, but the structure (the Expanded Program for Immunization) has been devolved, which flags the need for an appropriate transitional arrangement. Devolving these functions is neither cost effective nor in keeping with internationally prevailing trends. Furthermore, institutions like the Global fund and GAVI with potential and approved grants to the tune of billions envisage problems in having to deal with five entities instead of one mechanism and EAD may not fulfill requirements to be their Principal Recipient. We also need to be mindful of a potential reality—in the present global financial crunch, they can find this procedural difficulty as a reason to withdraw.
In the regulatory domain, functions have been retained at the federal level. Of the two kinds of regulatory arrangements envisioned, one is modeled on the design of other statuary and autonomous regulatory institutions recently created in Pakistan, which are placed under the oversight of the Cabinet Division without a reporting relationship with the concerned Ministry. The same is envisaged for the proposed Drug Regulatory Authority (DRA), a correct decision in principle. However, insights from past experiences can be instructive, in relation to ambiguity about the policymaking mandate, which can also be a problem for the DRA. These ambiguities have been discussed in these columns on April 30, 2011, and need to be carefully considered in transitional planning. Mandate related issues can also arise in other regulatory agencies—PMDC—which are not strictly “autonomous” and have now been placed under the division of Inter-provincial coordination, which also does not have the technical capacity to engage in this area.
The final question: where is the risk of fragmentation most detrimental? The most critical problem is in the area of health information. The Entry “..…extension from one province to the other of infectious…diseases” has been devolved to the provinces, vital health statistics has been given to FBS, emergency preparedness is now under Cabinet, Directorate of Central Health Establishment, under which some aspects of health-related border security fall, is under Planning Division and the agency, which should act as their apex, the National Health Information Resource Center, has been given to the National Institute of Health.
Fragmentation is also a concern in the policy arena, some elements of which are truly “national” in character. Fragmenting information and disjoining it from planning and policy simply means that the government is undermining its own mandate and decision-making ability in health.
To be continued…
The author is the founding president of the NGO think tank, Heartfile. sania@heartfile.org
Drug regulation and beyond
Published in The News International on June 25, 2011:
The establishment of a drug regulatory authority is once again on the policy agenda, this time round as part of implementation of the 18th Amendment-relevant devolution of health. In principle this is a step in the right direction. Whilst the service delivery functions of health need to be devolved, it is equally important to recognize that national health functions need to be served federally, as is the case in most federations around the world. In a recent analysis (http://www.heartfile.org/pdf/HEALTH_18AM_FINAL.pdf) four subjects have been described as falling within the purview of health’s ‘national roles’—information, regulation, international commitments, and several elements of policy. The policy rationale for retaining drug regulation at the national/federal level is robust in keeping with internationally prevailing trends. In addition, independent regulatory institutions are now a prerequisite in the post-WTO scenario since none of the flexibilities under the TRIPS agreement in terms of the rights of member countries can be availed unless there is an independent regulatory authority.
Work in this direction is not starting de novo. The draft “Ordinance to provide for the establishment of [the] Drug Regulatory Agency of Pakistan” (DRAP), a framework the Ministry of Health is supporting, is already on file. However, the situation has changed subsequent to the 18th Amendment and the MoH will have to review its draft law. There is an additional complexity related to the regulatory mandate in this area, which I have discussed in these columns on April 30, in “Mandate to regulate”. The Parliament has the powers to make regulatory agencies under Entry 6 of the Federal Legislative List, but the subject ‘medicines and drugs’ stands devolved. This raises the need for provinces to grant regulatory powers to the federation under Article 144 and 147 of the Constitution. Additionally, although all laws have been saved under 270, the question of the prerogative—parliament vis-à-vis provincial assembly—to amend the drug law loom.
Provinces, with Khyber Pakhtunkhwa (KP) taking a lead, have been reviewing the situation and have developed a position on this. In principle, three provinces are clearly supportive of retaining drug regulation nationally, but have some observations. One, that MoH’s draft law is federal-centric and does not provide for adequate representation of provinces in DRAP’s governance. Two, since the Drug Act 1976 appears as its schedule, it will not be within the purview of provincial assemblies. Three, that DRAP does not provide for a resource sharing formula where some revenue can be retained provincially, which is where manufacturing units reside. KP has proposed an alternative federal/national structure, where a Board with appropriate representation from provinces, overseen by a Council, performs the functions of licensing, pricing and registration. Their alternative draft law also takes into account other concerns mentioned above. The near-consensus to retain drug regulation nationally is positive and the next step should be for all stakeholders to develop a point of convergence. Since the DRAP Ordinance was developed in the pre-18th Amendment era, it is only logical that MoH should review it. With the right leadership a solution can be developed.
However, there are issues beyond DRAP which merit consideration. As work gets underway, there is the risk that attention will disproportionately focus on institutional attributes, which are seen as an end in themselves. It is important to recognize that creation of structures, appointment of members and definition of perks and privileges is not the ultimate desired outcome, just the means to an end. The idea is not just to find a way of mandating a federal agency with the responsibility of regulating drugs, but to achieve certain substantive objectives beyond that. Improvements in quality and elimination of malpractices in the medicines and related products chain is one, so that progress is possible towards the goal of making quality, efficacious and safe drugs affordable and accessible. The other objective is to foster competitiveness and create a level playing field for the industry so that the sector’s contributions towards the economy can be harnessed better.
The DRA can be an institutional vehicle to make headway in these desired directions. But in order for that to happen many things need to be done alongside the creation of DRAP. Three points are being outlined in this respect.
First, the notion of separating policymaking, from regulation/implementation and entrusting regulation to an independent agency is central to the concept of creating regulatory authorities. There are two questions here. The MoH envisages that health’s federal role will be served if a DRAP is created. This cannot be the case, as DRAP should have a regulatory but not a policymaking mandate. The latter will still need to be crafted in the federal purview. Where would such an entity sit when ideas to abolish the Ministry of Health are being mooted? The other question relates to the agency’s independence. Even if the DRAP is established as a statutory autonomous agency, is it likely to be independent? Past experiences with regulatory agencies do not inspire confidence. Members are handpicked and have defined allegiances, controls vest with government and in most cases independent regulatory agencies are just another level of cumbersome hierarchy in the decision-making chain. It is critical to address these concerns.
Secondly, the question of policy norms related to the three levels of regulation—quality, price and Intellectual Property Rights (IPR) regulation—is deeply related to the functioning of DRAP. Currently, the Drug Policy 1997 and Drug Act 1976 are in force, but many weaknesses exist. The drug rules are exploitable, particularly in relation to warranty of drug sale. ‘Nutritional’ and traditional medicines, prescribed by 130,000 practitioners of traditional medicine and devices and related healthcare technologies are outside of the drug act’s purview. Policy norms lag behind in relation to trends in technology, advertising and WTO agreements. There is need for a predictable and transparent pricing policy related to branded and generic medicines. These considerations call for updating norms and eliminating room for manoeuvring.
Thirdly, the value tagged to DRAP can be open to question if certain institutional constraints are not addressed. Elaborate regulatory arrangements exist even today at the federal and provincial levels. The real issue is at the level of capacity and transparency. Inspectors are poorly paid resulting in ‘subsistence corruption’. The numbers are paltry—250 for a population of 170 million. Drug-testing laboratories are few. Less than 2000 out of the 50,000 retail outlets employ qualified pharmacists while all the universities put together train less than 2000 pharmacists per year. Sale and resale of second-hand machinery is free, raw materials are traded in the open market, tariff collusion is rampant, hospitality-based incentive-intense marketing practices are endemic and back street manufacturing and spurious drugs continue to burgeon.
In order to mitigate these structural issues, a number of considerations will merit careful attention beyond the creation of DRAP. The onus of responsibility lies with the MoH who will have to provide the leadership for the needed transformation. There is no room for vested interest and incompetence here.
The author is the founding president of the NGO think tank, Heartfile. sania@heartfile.org
Solutions from within
Published in The News International on May 28, 2011:
The events of May 2nd and 21st have left the nation embarrassed and demoralized. The challenges arising as a result thereof may compound Pakistan’s existing problems. Many find it difficult to search for beacons of hope within the myriad of problems at a time like this. Within this context, this comment is an attempt to explore if there is reason for hope, and if so, what is it, that needs to transpire to turn the tide in a positive direction.
Whilst trying to frame an answer to this question, I am reminded of another question I was once asked at an international meeting: “how would you describe the Pakistani society?”
Struggling to portray a positive image of my country, I was fortunately able to quickly recall that a “society” is much broader than the “state” and that whilst the state may be predatory and beholden to capture at various levels, these attributes don’t necessarily describe societal characteristics. A society in any nation state comprises a number of human and institutional actors and relationships and is much broader than those concerning political aspects, which fall within the remit of the state.
The Pakistani society has many positive attributes. With respect to ideological trends, the society falls on the spectrum, with a majority subscribing to moderation as opposed to extremism, desirous of a peaceful, prosperous and progressive role for Pakistan in a globalized world. The Pakistani society has a strong tradition of volunteering and giving—not just rooted in faith but also as part of the sense of social responsibility. This attribute has come into play on several occasions at times of natural calamites, with the 2005 earthquake and more recent 2010 floods, being illustrative. It is also evidenced on an every day basis as the proportion of individual philanthropy supporting public hospitals and schools. The Pakistani societal fabric is woven deeply with family values, as a result of which the Pakistani diasporas remain committed to their roots.
We are the 6th largest country in the world, with a large segment of a population much younger, and potentially useful, than in other parts of the world. The Pakistani society is also a large consumer base, a large market, with a vibrant private sector. Despite the myriad of challenges in the country and the stagnant economy, consumer statistics have an upward trend, indicative of growing demand.
Moreover, there exists within the Pakistani milieu a vibrant civil society, which, subsequent to the lawyers’ movement has discovered its newfound strength. A tradition of activism appears to be burgeoning as a result. The country has a vibrant and free media, which has been proactive in shaping the societal political culture. Another strength of the Pakistani society, ironically, is its resilience. Millions of people survive in harsh economic circumstances; for many, the state exists only in the sense of the fragmented justice and law enforcement system they stumble on every now and then. They subsist without ever knowing what their rights are, and how the state fails them in its obligations.
Whilst these potential societal strengths exist, many challenges lurk. Societal fault lines are emerging with religion, ethnicity and social inequities as their basis and ideological allegiances are fast polarizing. The population ‘dividend’ is becoming increasingly untenable. The burgeoning market is fast becoming a prey to organized cartels and the informal and black economy is increasing in quantum. Vested interests groups are organizing within the civil society. Factions within the media are falling prey to capture. The resilient poor are being pushed to the limit as sluggish growth, compounded by the energy crisis increases unemployment and high inflation assumes a backbreaking magnitude. It is important to recognize that it is weaknesses at the level of the state, which are fast eroding most of the strengths within the society.
The role of a strong state in harnessing societal strengths for improving national outcomes should not be underestimated. The population dividend can hold promise, if it is harnessed with the right vision for a growth strategy, led and implemented by successive responsible governments in an environment of policy consistency. The remarkable societal attribute of giving, supporting and contributing can be amplified if synergies are exploited systemically through legal and fiscal instruments, which incentivize philanthropy both for the indigenous population as well the diasporas and through mechanisms that can demonstrate transparent use of contributions towards national causes. The state can make the market work for equity and quality, harness entrepreneurial talent of the private sector for revitalizing state enterprise, leverage outreach of private providers for public goals, capitalize civil society’s independent spirit and innovative thinking, ride the media wave for strengthening the societal fabric, the list of opportunities can go on.
Most importantly, it is only through an honest, impartial and uncolored hand of the state that the channels of resources, which feed the extremist elements, can be plugged. It is only the state which can checkmate mafia groups, their predatory behaviors, and their inextricable relationship with political party finance. These systemic fault-lines are playing havoc with law and order. In addition to threatening lives they are having a domino effect on the economy and are further deepening inequities in the society, which have a chicken and egg relationship with unrest and violence, perpetuating a vicious cycle.
It is time for a reality check. We must recognize that our failures are largely indigenously manufactured. Rather than blaming external actors, it is best to look inwards for fault-lines that can be cemented.
We must know that our biggest security threat today is lack of economic security and that the country’s most pervasive limitations are technological, knowledge base and human resource capacity related. We must recognize that our lack of integration with the global economic system is a major disadvantage. The biggest threat to the country comes not from outside but from our own short fallings. From our failure to ensure separation of powers between the pillars of the state and institutionalize checks and balances. From our inability to uphold the principles of democracy and the practice of openness and collective deliberations, consensus-building, participation and evidence-based decision-making, critically important attributes in statecraft. From our failure to build safeguards against abuse, collusion and patronage and our ambivalence to the lack of fairness, transparency and accountability within the system.
The solutions to these problems will not come in the shape of “external assistance”. They have to emanate constructively from within us. Leadership, at all levels of society, with a vision for unity, hope and discipline is the need of the hour. In one of my forthcoming comments I will attempt to draw a list of what will help and how each one of us can contribute.
The author is the founding president of the thinktank, Heartfile. sania@heartfile.org
Pakistan prepares to abolish Ministry of Health.
Nishtar S, Mehboob AB. Pakistan prepares to abolish Ministry of Health. The Lancet May 4, 2011
Mandate to regulate
Published in The News International on April 23, 2011:
As one of the key instruments of governance, regulatory functions have increasingly been in the spotlight, subsequent to the 18th Constitutional Amendment.
Regulation can take many forms but in the current context it refer to interventions initiated by the government to correct market failure, or the use of state power to impose constraints on organizations and individuals through a range of instruments issued by the government or non-governmental bodies to which the government has delegated regulatory powers. Amongst the things that can be regulated, price, quality, and numbers are the most salient.
The mandate to regulate is sometimes the basis of tenuous relationship between a federation and its federating units and can lead to unnecessary turf rivalries between different levels of government. Such problems could emerge in Pakistan as provinces discover their newfound regulatory prerogatives after the 18th Amendment. With calls for new provinces whipping up, the ramifications of this trend could be immense.
The recent controversy over devolving the Higher Education Commission (HEC) helps to illustrate this point. Amongst other things, the HEC is also a regulatory agency, prescribing standards and ensuring compliance. Proponents of devolving HEC opine that education is a provincial subject whilst those that argue for its national role bring to bear its regulatory function as a justification for its existence at the federal level—a role, which the Implementation Commission has now accepted and is working towards retaining. Drug regulation is another example, which is a federal subject in most countries of the world—in fact regional regulatory models are coming up, evident in arrangements in the European Union, Gulf Cooperation Council countries and Latin America.
The question of regulatory prerogatives has many dimensions—questions about national roles in subjects that have been devolved and the much bigger debate about defining national roles in federating systems in a globalized world where there is need for uniformity of standards.
Federating systems in the developing world usually centralize normative aspects of regulation and tend to devolve implementing arrangements. The former is done to maintain uniformity and obviate duplication.
Those that drafted the 18th Amendment were cognizant of the importance of a federal role in regulation and hence an Entry was introduced in Part II of the Federal Legislative List “All regulatory authorities established under a federal law”. However, there are questions centered on the validity of creating a regulatory authority to regulate a subject, which has been devolved by the 18th Amendment. This is illustrated in a question, which has arisen in the Sindh High Court with filing of a case against the Pakistan Standards and Quality Control Authority, which was created in exercise of the powers under a Federal law—the Pakistan Standards and Quality Control Act, 1996. The federal authority prescribes standards in an area—sugar—which, as an agricultural produce, is a provincial subject. The question relating to the validity of federal regulation in a devolved subject is also relevant to drug regulation—Entry 20 “drugs and medicines” was part of the omitted Concurrent Legislative List.
In view of this ambiguity, various views are being mooted to establish a constitutional justification for retaining a federal regulatory role in the post 18th Amendment scenario. One view refers to Article 270AA(6) of the 18th Amendment, which saves all laws with respect to the omitted CLL, enacted prior to the 18th Amendment. These laws continue to remain in force until altered, repealed or amended by the ‘competent authority.’ However, this notion is subject to several concerns. First is the question of sub-constitutional vs. the Constitutional law, with the latter being supreme. Also, the expressions ‘saved’ and ‘competent authority’ have legal connotations in Article 270AAA. While laws have been saved, there are questions about who the ‘competent authority’ is with reference to the power to amend laws. Provincial assemblies and not the Parliament may now be the competent authorities in the given context.
Secondly, experts are also drawing on the example of the USA, where the power to regulate can be exercised by virtue of the federal subject of interstate commerce. An analogy is being drawn with the prerogative in inter-provincial commerce and federal powers by virtue of Article 151 read with Entry 6 of Part II of the FLL. However, other experts are of the opinion that on a textual analysis, Article 151 does not seem to cover ‘regulation,’ as understood in the present context.
The third potential mechanism, may be to have any draft law to create a federal regulatory authority approved by the Council of Common Interests (CCI) prior to promulgation by the Parliament. Subsequent to enactment, such regulatory authority would be subject to supervision and control of the CCI at which the four Chief Ministers and the federal government are represented. Based on this, it could be argued that through the forum of CCI, the provinces have acquiesced in the federal government, regulation of an otherwise devolved subject. However, one key weakness in this approach is the counter-argument that the Chief Ministers, whilst participating in the CCI, do not directly represent or are synonymous with the provincial assemblies to which the ‘legislative authority’ in respect of the relevant subjects has been devolved and hence, on a strict interpretation, do not posses the authority and power to empower the Parliament to enact a law which is the constitutional prerogative of the provincial assemblies. Such approach could also be criticized as a circumvention of the mechanism expressly provided in Article 144.
In sum, therefore, all the constitutional mechanisms being cited as the basis for retaining regulation at the federal level are fraught with some degree of uncertainty. Article 144 is the only valid and non-controversial mechanism in the Constitution, which can grant a regulatory mandate to the federal level. It is now imperative that provincial assemblies recognize the imperative and grant the federation a mandate related to regulation, where necessary. The federal government must, in turn, reform its own ability to regulate—its track record is less than desirable. The provinces will still continue to play a role in regulation in such an arrangement through policy oversight enabled through the CCI.
The political and constitutional imperative of political autonomy is well appreciated. Within that context, the 18th Amendment is an important game-changing intervention. However, it is inevitable that many questions will arise in the wake of such a major transformation. The question related to regulatory prerogatives is just one of them. It is critical to carefully think through these questions so that progress towards the premise enshrined within the 18th Amendment can be sustained.
The author is the founding president of the thinktank, Heartfile. sania@heartfile.org
Priority actions for the non-communicable disease crisis
Priority actions for the non-communicable disease crisis. Lancet. 2011 Apr 23;377(9775):1438-47.
Health and the 18th Amendment
Published in The News International on April 02, 2011:
The Implementation Commission of the 18th Constitutional Amendment, in its recent session, has taken the final decision to devolve the Ministry of Education. The next round of deliberations will decide the modalities of devolving another set of ministries, including the Ministry of Health (MoH). My comment in these columns on December 25, 2010—the Vanishing Ministry—outlined several institutional considerations that need attention whilst making decisions in this regard. One of these refers to the question of the national role in health and related institutional arrangements. Lessons from other countries are instructive in this regard. There are at least 25 countries with federating structures where health is a fully devolved subject. All have federal institutions—a ministry, state department, directorates or equivalent institutions—taking responsibility for “national mandates” in health.
For this and many other reasons, there is a strong case arguing against MoH’s abolition.
Contrary to what is being planned, there is need for stepping up capacity within the MoH, as there are many ominous indications of its constrained capacity—the case of polio and H1NI are illustrative in this regard. But it seems, however, that for the Implementation Commission, “ministerial abolition” in subjects, which have been devolved, has become symbolic of the entire process of devolution. In view of this, the best option is to develop a constitutional solution for establishing a national role in health.
Within this context, this viewpoint is being used to draw attention to a recently conducted analysis, on which inputs are being solicited. The paper presents the technical and constitutional rationale for retaining the national role in health and discusses options for a way forward as the Implementation Commission opens its discussions on the subject.
The paper defines the following as national functions in health: health information and disease security, international commitments, drug regulation, certain aspects of human resource regulation, overarching norms, and standards where inter-provincial conformity is needed. It then goes on to discuss the impact of certain changes brought about by the 18th Amendment on these national functions—abolition of he Concurrent Legislative List (CLL), shifting of Entrees from Part 1 to Part 2 of the Federal Legislative List (FLL), insertion of a new Entry in Part 1 of the FLL, amendments in Article 144 and 270.
The analysis opines that although sweeping changes have been made by the 18th Amendment, the Constitution of Pakistan still provides space for the federal level to assume responsibilities for most of the national functions referred to above. The only exception is drugs, where the constitutional prerogative to retain the federal role without the consent of the concerned provincial legislature, is less clear.
While supporting “devolution of health” overall, the paper makes a strong case for also retaining a “national role in health” and underscores the need for an appropriate federal institutional arrangement to fulfill national health responsibilities. Attention is drawn to constitutional provisions and rules of business of the federal government, which when viewed in context of the present devolution drive, call for creating a Health Division.
The paper also discusses systemic challenges, which plague the current MoH and stresses on the need to use the present opportunity to bridge these weaknesses as the ministry is “recast” as a Division. The relationship of five institutional steams, which are envisaged to report to/link with the Health Division, has been elaborated.
On the question of the health policymaking prerogative, it has been accepted that with the responsibility for health completely devolved, the policymaking role has automatically been transferred to provinces. This notwithstanding, areas within the national policy purview have been enumerated and the convening fora for mandates granted to the national level under Part I and II of the FLL have been discussed—in particular prerogatives of the Cabinet vs. the Council of Common Interest.
On the subject of regulation, the paper refers to the post-18th Amendment prerogative of the Parliament to create federal regulatory authorities and alludes to the problem which can arise when the subject for which a federal regulatory agency is created, is devolved. The complexity of this for the area of drugs regulation has been alluded to in detail in the paper. This consideration has implications for the regulatory mandate in many other areas/subjects, and deserves a dedicated discussion in another comment.
With respect to drugs, the paper emphasizes the strong policy rationale for retaining regulation at the national/federal level and elaborates why the appropriate constitutional mechanism to enable that is Article 144. Other subjects touched upon in the paper include national functions with respect to service delivery, national public health programs, health information systems, human resource, federal fiscalism, health financing and international agreements.
With respect to the national public health programs, incremental devolution has been recommended and a unified interim federal structure has been described to assume responsibility till such time that provincial capacity is fully developed. A case has been made for folding all programmatic activities, such as research, health information and mobile service delivery, in other cross-cutting interventions. The need for retaining a unified minimal federal structure has also been flagged to support functions on an ongoing basis where inter-provincial policy coordination is needed.
The analysis states how the amendment does not drastically alter federal functions related to human resource but describes the interplay of provincial concurrence, which may now become necessary for human resource decisions at the federal level. A section of the analysis clarifies the constitutional position with regard to health information, which the viewpoint argues is an important national/federal responsibility in the wake of disease security concerns. It clarifies that constitutional provisions potentially enable the function to be retained federally, but makes a strong case for reform of the health information institutional landscape to bridge current weaknesses in individual streams. It also calls for creating an apex mechanism to comply with International Health Regulations, 2005.
Through this comment, I am soliciting inputs on the draft paper. A copy of the latter can be made available by sending a request at sania@heartfile.org. Meaningful feedback will be collated and acknowledged in the paper. This comment will also be followed by a more generic comment, which draws on insights from the analysis for other sectors.
The author is the founding president of the thinktank, Heartfile. sania@heartfile.org
Doctors’ movement
Published in The News International on March 19, 2011:
Young doctors in the largest province of the country are on strike for the 17th day running. With revolutionary fervor from the lawyers’ movement and the Middle Eastern revolutions shaping our societal political culture, it seems that the movement is having a snowball effect. An increasing number of young doctors, groups and associations are galvanizing support for the Young Doctors Association, the apex body, which lent impetus to this movement. Their cause is becoming a rallying cry for drawing attention to a number of systemic constraints in relation to human resource issues as they impact young doctors.
Their demands are legitimate—pay raise, pay protection, increase in health budget, and implementation of a service structure and regularization of doctors on contract. However, the determinants of the problem and possible policy approaches are complex and multi-dimensional. This comment aims to highlight some of the policy insights and imperatives which interplay in this complex space.
First, these demands have arisen in a fiscal year where there has been a massive development budgetary squeeze, after the floods of 2010. This is also a year where there is an elephant in the room—the 18th Amendment has altered the health sector’s institutional landscape and several administrative and human resource related parameters are in a flux. As implementation of devolution gets underway, management of human resource service structures will be problematic and will need careful management.
Secondly, inadequate remuneration of doctors is part of an overarching problem—low investments in social service delivery in general and health in particular. Chronic under-funding of the state’s health infrastructure is the major fault line. As a result, providers in the public system are seldom remunerated according to prevailing market trends. This creates problems at several levels. On the one hand, as a result of better incentives in the private system, doctors are driven to private practice and establishing private enterprises. In urban settings where some level of oversight can be maintained, this results in dual job-holding, with doctors working both in the public as well as the private system. However in rural/remote areas where oversight cannot be maintained, absenteeism is rampant. Public doctors simply do not serve in the public system. Some are maintained on salary books only and exist as “ghost workers”. Chronic under-funding of the public system, coupled with an unregulated burgeoning role of the market in health and lack of transparency in overall health governance also create a number of other distortions in the health system, which I have alluded to in my book, Choked Pipes. There are options available to plan and institutionalize reform to overcome these distortions. Various entry points exist through which reform can be initiated—changes in human resource structures one of them and it is here that understanding the dynamics which shape the young doctors’ recent protests assumes importance.
Human resource and health systems are deeply inter-woven. Human resource is not just another input into the health system, as are financial and physical resources. Individuals are strategic actors within the system who can act individually or collectively to facilitate the process of change by improving quality and efficiency. Conversely, they can also be the critical impediment to a reform process.
For example, decentralization can grant appropriate prerogatives and/or take away decision-making powers that promote arbitrariness. Pakistan has experimented copiously with deploying and de-tracking from decentralization of the local government system, 2001 onwards. Its fall out is evident in many areas, but is most evident in the area of human resources for health, where a high degree of uncertainty shrouds workers’ performance. The premise behind the devolution initiative has almost been defeated.
Another example is the area of “outsourcing” and “contracting out”, which can impact working conditions. New service delivery arrangements, public-private redeployment and new recruitment and retention mechanisms, can either be perceived as a threat or present a conducive environment for enhancing performance. An illustration of this is the Peoples/Presidents Primary HealthCare Initiative, where entrenched bureaucracies are the actual impediment to the process of scaling up reform.
A similar situation applies to past experiences in granting public hospitals autonomy where staff incentive is the core driver determining outcomes. Changing public service status as a result of reform is another factor as it can have implications for workload in addition to incentives. Implementation of Khyber-Pakhtunkhwa’s hospital autonomy policy in 2002 is a case in point as it sparked strikes and demonstrations by paramedics, who feared losing their flexible public job status by being part of a more stringently governed private sector. The critical role of human resource in shaping the direction of envisaged change should, therefore, not be under-estimated—ongoing protests must be viewed in light of this understanding.
Thirdly, this situation should draw the attention of policymakers to the lack of existence of a comprehensive policy on human resources for heath in the country. There are three issues in relation to the health service delivery workforce, which need attention—numerical inadequacies, issues related to distribution and deployment, and problems with capacity building and training. While the number of doctors in the country has increased since 1947, critical numerical inadequacies prevail. The doctor nurse ratio is 2.7:1 as opposed to the internationally recommended 1:4. There is critical shortfall of many other categories of health workers. This has been compounded by mal-distribution, ineffective deployment, and uneven distribution between the rural and urban areas. Many issues need to be addressed in the domain of under-graduate and postgraduate education, in-service training, and continuing education. Each of these has to be relevant to the needs of respective health professionals. There is the additional dimension of problems related to human resources for health administration particularly with reference to staffing key governance positions, training and capacity building and institutionalizing accountability. Over the years, political and external interference in decisions, particularly in relation to recruitment, transfers and disciplinary actions has become deeply ingrained. Erosion of mechanisms to compel accountability and politicization of governance are an impediment for efficiency and a demoralizing factor within the public sector.
A human resource policy needs to be developed taking all these factors into consideration. The policy should be based on an objective assessment of needs and can benefit from being translated into a Health Services Law, which encompasses all categories of healthcare providers and lays down consensus-driven roles and prerogatives. Insights can also be drawn from the recommendations of the National Commission on Government Reforms, which have not been implemented.
Despite our Pandora of problems, Pakistan’s societal political culture is getting stronger with increasing awareness amongst people about matters, which impact their rights and well being. Pakistan’s decision makers must accord careful attention to such movements in an overall environment charged with revolutionary fervor.
The author is the founding president of the NGO think tank, Heartfile. sania@heartfile.org
The Challenges of Scaling up.
Nishtar S. The Challenges of Scaling up. Lancet 2011;377:986.
Non-communicable diseases: evidence-policy disconnect
Published in The News International on February 12, 2011:
World Bank’s report ‘Tackling Non-communicable Diseases in South Asia’ made headlines in Pakistan, yesterday. This is an important subject and its significance should be appreciated by policymakers. The report highlights the magnitude of burden attributable to a set of diseases, widely prevalent throughout all countries of south Asia—diseases which are linked by common risk factors, are largely preventable through cost effective interventions, but which have remained outside of traditional public health planning. It is now well established that certain heart diseases, stroke, diabetes, and some cancers and chronic lung conditions are the biggest global killers. In Pakistan they are the leading preventable cause of death, disease and disability in the adult population. These diseases have enormous social and economic costs with a serious negative impact on human and economic development. They impede progress toward the UN Millennium Development Goals, particularly toward poverty reduction and lead families into the medical-poverty trap. Yet, the prevention and control of Non-communicable diseases (NCDs) is outside of mainstream public health planning in Pakistan. It is neither part of the development agenda nor poverty reduction strategy plans. Lack of attention to NCDs is the greatest paradox in public health. Now that there is a beginning of global attention toward this issue, it is important that commensurate action be stepped up to address this challenge.
The NCDs issue can also be used as a lens to examine broader governance challenges related to the use of evidence in policy and planning in the country. Data from the Pakistan Demographic Surveys (PDS) is a case in point. PDS is a sample surveillance system, which measures vital events (births, deaths) annually and is conducted by the Federal Bureau of Statistics (FBS), Government of Pakistan. Surveys have been conducted sequentially since 1992 and results have consistently shown that NCDs are the major killers in the adult population. The percentage of deaths attributable to NCDs increased from 34.1% in 1992 to 59% in 2005 according to respective surveys. This compelling evidence was consistently paralleled with lack of priority accorded to NCDs in planning and resource allocation decisions. Public health planning in Pakistan remained dominated by infectious diseases and NCDs remained outside of mainstream planning.
Attempts were made previously in Pakistan through public-private collaborative efforts to plan strategically in this area and a national plan of action was published. This effort was acknowledged in World Bank’s report as the first integrated national plan of action from within the developing countries. Implementation was thwarted largely since NCDs were not part of the official health policy in Pakistan and remained outside of donors’ priorities. NCDs were the blind spot of the 2001 National Health Policy, while data and evidence from the state’s own data collection engine, FBS, continued to point toward an escalating trend. This, highlights a fundamental disconnect between evidence and policy. Disconnect could also be visible in other areas and does not auger well for appropriateness of the policymaking process. The gap must be bridged to eliminate the influence of arbitrariness in the decision-making process.
There is also another policy issue at the margins of this discussion—efforts underway to restructure FBS as an autonomous organization through an Act of Parliament. Reconstruction along these lines is needed so that this key agency, responsible for data and evidence can be isolated from interference and manipulation. Ensuring independent functioning of autonomous agencies has been Pakistan’s predicament. Governance challenges in this space need to be addressed. Alongside, it is also critical to ensure that mechanisms are in place to bridge the current evidence-policy disconnect.
Turning back to NCDs, Pakistan needs to recognize what it means in policy and planning terms to institutionalize their prevention and control in its health and development systems. NCDs are linked by certain risk lifestyle factors—tobacco use, lack of physical activity, unhealthy diet and alcohol use. Biological factors add to the risk—obesity, high blood pressure and abnormal cholesterol levels. As these are related to individual behaviors, people need to take responsibility. However, policy action is necessary to create supportive environments. This is where solutions to prevent NCDs are different from what Pakistan’s health sector is familiar with. These solutions lie largely outside the health sector and involve trade policy, taxation, international regulation, the agriculture and environment sectors, general working and living conditions, cross border smuggling and functioning of the local government system. Cutting unhealthy fats from the diet, lowering salt, promoting exercise at the individual and community level, in work place and schools, making urban environments conducive for physical activity, overcoming barriers for women to participate in physical activity in our conservative culture, controls on tobacco advertising, price regulation, promoting healthier eating etc., are all public health interventions to curb NCD risks. These are outside the remit of traditional health planning but now need to be at the heart of public health strategies. Pakistan’s public health system needs to create institutional arrangements with a mutli-sectoral construct and scope beyond the health sector to enable effective inter-sectoal action in this space. On that note it is sobering to recognize that the current capacity and resources in the system to enable that are extremely limited.
There is a health care dimension to NCDs as well, which entails ensuring availability and access to cost-effective medial and screening interventions to those who need them. The country needs to step-up evidence-based interventions, which have been demonstrated as having the potential to effectively treat individuals with disease and protect those who are at high risk of developing them. There is need for building capacity at the health systems level and reorienting health systems towards chronic care with attention to human resource, service delivery, surveillance and access to essential medicines. Services related to NCDs need to be integrated in primary healthcare and essential services packages. All this is likely to be a challenge for Pakistan’s under performing public health system, where capacity constraints abound. Failure to eradicate polio is an indicator of these constraints.
Let us also be reminded that Pakistan’s health governance system is currently in flux. The MOH will be abolished in 4 months from now and the fate of the local government system, the functioning of which determines the effectiveness of health service delivery, is still undecided. This a time of great challenges for health—but this is also an opportunity.
An unprecedented discourse is currently underway to reshape federal-provincial and provincial-district interfaces with a view to devolving health under a new constitutional framework. While this big ticket restructuring fundamentally opens many avenues for reforming health service delivery, it also offers opportunities to integrate NCDs within in the public health system. Efforts to mainstream NCDs into country health planning can have a significant knock-on effect on health systems and can be an entry point to reform itself.
Pakistan needs to gear up planning in this area. In September 2011, United Nations General Assembly Special Session on NCDs will be convened. Pakistan must showcase something substantial in the run up to that watershed event.
The author is the founding president of the NGO thinktank, Heartfile. E mail: sania@heartfile.org
Operation polio
Published in The News International on January 29, 2011:
The government and opposition factions appear to be converging on a ten-point Agenda focused on eliminating some of the currently prevailing governance distortions in Pakistan. Articulated as a set of “Demands” by one particular opposition party, the points have been endorsed by others and have been admirably embraced by the incumbent federal government. The ten-points, per se, are non-controversial and there appears to be a broad consensus that action towards them will contribute positively in an environment where mistrust and malfunction are now deeply ingrained. This comment is aimed at explaining that whilst these points are significant stepping stones, and are important in their own right, they are nevertheless inadequate for addressing deeply rooted systemic issues, which can only be amenable to reform at a more fundamental level. Three points are being highlighted to elaborate this further.
Six of the ten demands center on eliminating corruption in one way or the other. The demands to dismiss Cabinet members and personnel in high offices with tainted credentials, dealing with culprits of the recent Hajj, banking, privatization and procurement scams and bringing perpetrators of the recent commodity hoardings to justice fall under this category. Additionally, the demand to implement the supreme courts’ verdict in the aftermath of the National Reconciliation Ordinance being regarded null and void also falls within this rubric.
There is a long standing history of attempts to address corruption through disciplinary and penalizing action in Pakistan. Whilst it is true that punitive action has its value as it sets an example and acts as a deterrent, it has its limitations. Political governments and decision makers, deeply entrenched in the spirit of camaraderie are reluctant to bring their peers to justice. With many opportunities to abuse discretionary powers, disciplinary efforts often take on politically-motivated overtures. Pakistan has made the mistake of focusing on corruption through the predominant focus on this approach for far too long. As a consequence, other more systemically effective means of garnering a culture of transparency in overall governance, have received little emphasis. More than punitive action, the key to anticorruption is to focus attention on building institutions and systems that limit opportunities of collusion, graft and arbitrage in the first place. An important aspect of this is mechanisms of oversight that can check discretionary powers, which create opaqueness in interpretation and variance in application of policies. There is potential within leveraging technology as a barrier against abuse and pilferage. Promoting market harnessing means of regulation, fostering competition to weaken economic interests and integrity-promoting measures in the bureaucracy are other entry points. The dividends of appropriate disclosure and freedom of information and safeguards against conflict of interest should additionally be brought to bear. Furthermore, one of the most effective anti-corruption strategies has to do with building safeguards against state capture and the legacy of patronage; this can be attempted by upholding democratic principles in governance so that the systemic manipulation by vested interest groups, which has become a governance norm in our country, can be circumvented.
Punitive actions being recommended as part of the Agenda, therefore, need to be supplemented with a greater emphasis on strengthening Pakistan’s key institutions in general and accountability mechanisms in particular and implementing the country’s National Anti Corruption Strategy, which seems to have gone into hibernation after its unveiling in 2002 and several successive attempts aimed at reviving it.
The second demand on the Agenda calls for the creation of an independent Accountability Commission. It is widely accepted that impartial and depoliticized accountability bodies can help advance the accountability/transparency agenda. However, the past performance of commissions in Pakistan has not been promising and nothing harvests the hope that the case is likely to be otherwise this time round.
Commissions tend to fall prey to capture and end up behaving quite similar to bureaucratic structures. There are additional issues with the proposed accountability commission. The law under which it is supposed to be created and which has been pending in the Parliament/ Ministry of Law for over a year has been criticized because of its glaring list of exclusions and loopholes, which can enable exploitation. Furthermore, accountability is a broader thread in governance and is not synonymous with anticorruption. As an attribute, it is also relevant to the performance and financial realms. The determinants of the fiscal policy related Demands on the Agenda can be explored further to highlight the reality that Pakistan’s systems of governance are bereft of any such effective structures. These demands relate to inflationary pressures, the energy crises, crowding out of fiscal space, sprawling size of the government and resulting expenditures. Each of these threads can be linked back to lack of effective mechanisms of accountability at the performance and financial levels.
If mechanisms to compel accountability existed and if disclosure and freedom of information laws had been implemented in their true spirit to assist with the accountability process, perhaps Pakistan’s debt burden would not have accumulated to this scale and its footprint on the lives of the common man in terms of inflationary pressures and scaled back social services would not have been this brutal. The blatant graft, which leads to massive bleeds from the system, may not have been so deeply entrenched crowding out the space for resources, which can touch the lives of a common man. The Public Sector Development Programme would not have continued to fund public sector enterprises and infrastructure projects with meager development resources at the cost of health and education while options to revitalize management and privatization for the former and private financing for the later existed. If accountability had been institutionalized, the energy czars would have not prioritized quick turnover thermal power plants over long term sustainable investments in hydel power projects; the common man would not have to bear the weight of massive load-shedding, which is having a domino effect on employment and the economy. There is a long list of illustrative examples to highlight the manner in which lack of accountability at the decision making level has translated into the current mayhem. So, important as the agenda targets may be, it will take more than a Commission to set things on the right path.
The third aspect of the Agenda I would like to comment on is the Call for an independent Election Commission. Perhaps what the agenda should have stressed on additionally is also to expedite and support what is already in the pipeline. The NEWS on January 12 featured a seemingly non-descript but an important news item regarding the National Database Registration Authority’s efforts to install an electronic voting system and a law in the pipeline to enable that. Ideally this should be supplemented with other reforms to make the election process more facilitative for those that neither have the power nor the money to enter the run. Additionally the illiterate voter, currently beholden to feudal interests and dynamics of ‘biradrai’ will also have to be primed to the need for making the right choice. What Pakistan needs now is human capital in the right policy making roles with the hope that this will set key institutions on the pathway of recovery. The Agenda Demands need to be augmented to make headway in that direction.
The author is the founding president of the NGO think-tank, Heartfile. sania@heartfile.org
Anti-corruption strategies
Published in The News International on January 05, 2011:
The government and opposition factions appear to be converging on a ten-point Agenda focused on eliminating some of the currently prevailing governance distortions in Pakistan. Articulated as a set of “Demands” by one particular opposition party, the points have been endorsed by others and have been admirably embraced by the incumbent federal government. The ten-points, per se, are non-controversial and there appears to be a broad consensus that action towards them will contribute positively in an environment where mistrust and malfunction are now deeply ingrained. This comment is aimed at explaining that whilst these points are significant stepping stones, and are important in their own right, they are nevertheless inadequate for addressing deeply rooted systemic issues, which can only be amenable to reform at a more fundamental level. Three points are being highlighted to elaborate this further.
Six of the ten demands center on eliminating corruption in one way or the other. The demands to dismiss Cabinet members and personnel in high offices with tainted credentials, dealing with culprits of the recent Hajj, banking, privatization and procurement scams and bringing perpetrators of the recent commodity hoardings to justice fall under this category. Additionally, the demand to implement the supreme courts’ verdict in the aftermath of the National Reconciliation Ordinance being regarded null and void also falls within this rubric.
There is a long standing history of attempts to address corruption through disciplinary and penalizing action in Pakistan. Whilst it is true that punitive action has its value as it sets an example and acts as a deterrent, it has its limitations. Political governments and decision makers, deeply entrenched in the spirit of camaraderie are reluctant to bring their peers to justice. With many opportunities to abuse discretionary powers, disciplinary efforts often take on politically-motivated overtures. Pakistan has made the mistake of focusing on corruption through the predominant focus on this approach for far too long. As a consequence, other more systemically effective means of garnering a culture of transparency in overall governance, have received little emphasis. More than punitive action, the key to anticorruption is to focus attention on building institutions and systems that limit opportunities of collusion, graft and arbitrage in the first place. An important aspect of this is mechanisms of oversight that can check discretionary powers, which create opaqueness in interpretation and variance in application of policies. There is potential within leveraging technology as a barrier against abuse and pilferage. Promoting market harnessing means of regulation, fostering competition to weaken economic interests and integrity-promoting measures in the bureaucracy are other entry points. The dividends of appropriate disclosure and freedom of information and safeguards against conflict of interest should additionally be brought to bear. Furthermore, one of the most effective anti-corruption strategies has to do with building safeguards against state capture and the legacy of patronage; this can be attempted by upholding democratic principles in governance so that the systemic manipulation by vested interest groups, which has become a governance norm in our country, can be circumvented.
Punitive actions being recommended as part of the Agenda, therefore, need to be supplemented with a greater emphasis on strengthening Pakistan’s key institutions in general and accountability mechanisms in particular and implementing the country’s National Anti Corruption Strategy, which seems to have gone into hibernation after its unveiling in 2002 and several successive attempts aimed at reviving it.
The second demand on the Agenda calls for the creation of an independent Accountability Commission. It is widely accepted that impartial and depoliticized accountability bodies can help advance the accountability/transparency agenda. However, the past performance of commissions in Pakistan has not been promising and nothing harvests the hope that the case is likely to be otherwise this time round.
Commissions tend to fall prey to capture and end up behaving quite similar to bureaucratic structures. There are additional issues with the proposed accountability commission. The law under which it is supposed to be created and which has been pending in the Parliament/ Ministry of Law for over a year has been criticized because of its glaring list of exclusions and loopholes, which can enable exploitation. Furthermore, accountability is a broader thread in governance and is not synonymous with anticorruption. As an attribute, it is also relevant to the performance and financial realms. The determinants of the fiscal policy related Demands on the Agenda can be explored further to highlight the reality that Pakistan’s systems of governance are bereft of any such effective structures. These demands relate to inflationary pressures, the energy crises, crowding out of fiscal space, sprawling size of the government and resulting expenditures. Each of these threads can be linked back to lack of effective mechanisms of accountability at the performance and financial levels.
If mechanisms to compel accountability existed and if disclosure and freedom of information laws had been implemented in their true spirit to assist with the accountability process, perhaps Pakistan’s debt burden would not have accumulated to this scale and its footprint on the lives of the common man in terms of inflationary pressures and scaled back social services would not have been this brutal. The blatant graft, which leads to massive bleeds from the system, may not have been so deeply entrenched crowding out the space for resources, which can touch the lives of a common man. The Public Sector Development Programme would not have continued to fund public sector enterprises and infrastructure projects with meager development resources at the cost of health and education while options to revitalize management and privatization for the former and private financing for the later existed. If accountability had been institutionalized, the energy czars would have not prioritized quick turnover thermal power plants over long term sustainable investments in hydel power projects; the common man would not have to bear the weight of massive load-shedding, which is having a domino effect on employment and the economy. There is a long list of illustrative examples to highlight the manner in which lack of accountability at the decision making level has translated into the current mayhem. So, important as the agenda targets may be, it will take more than a Commission to set things on the right path.
The third aspect of the Agenda I would like to comment on is the Call for an independent Election Commission. Perhaps what the agenda should have stressed on additionally is also to expedite and support what is already in the pipeline. The NEWS on January 12 featured a seemingly non-descript but an important news item regarding the National Database Registration Authority’s efforts to install an electronic voting system and a law in the pipeline to enable that. Ideally this should be supplemented with other reforms to make the election process more facilitative for those that neither have the power nor the money to enter the run. Additionally the illiterate voter, currently beholden to feudal interests and dynamics of ‘biradrai’ will also have to be primed to the need for making the right choice. What Pakistan needs now is human capital in the right policy making roles with the hope that this will set key institutions on the pathway of recovery. The Agenda Demands need to be augmented to make headway in that direction.
The author is the founding president of the NGO think-tank, Heartfile. sania@heartfile.org
Risks and resilience
Published in The News International on January 01, 2011:
At the recent meeting of the Global Agenda Council of the World Economic Forum in Dubai some of the top issues in the global risk landscape and their possible mitigates were highlights. Ironically, a few of us from Pakistan could relate to most systemic risks as being endemic to our sovereign environment, each of them inextricably multi-dimensional in their scope. As global experts underscored the salience of effective governance structures, accountability, and clarity in multi-stakeholder concerted action as the means of addressing these risks, one could not help reflect on ones own constraints within that space.
Reflecting on these risks and the mechanisms that can ensure institutional and population resilience is part of what one should be doing at the turn of the decade.
Against the backdrop of mayhem caused by Iceland’s Volcano and the recent unexpected weather on Christmas Eve, probably the beginnings of manifestations of the “inconvenient truth”, the agenda of climate change and the modest progress achieved in Cancun are now a major point of reflection, globally. Pakistan has recently learnt some bitter lessons which drove home the importance of natural calamities and their inter-linkages with climate change. The widespread inundation and damage consequent to the 2010 floods may not have received the support it deserved from the international community particularly vis-à-vis Haiti earthquake and the earlier Tsunami, it nevertheless speaks volumes about resilience of the poor in the riverside communities of the Indus river. The response of the domestic and expatriate Pakistanis was additionally indicative of community resilience. The same cannot be said for the systems of governance though. Our disaster management systems need significant injection of resources and capacity building in order to be effective.
Someone once very appropriately stated: “half of Pakistan is seismically active and the rest is flood prone” may I add that nearly all is vulnerable to terrorist attacks. Terrorism featured prominently as a global threat. Pakistan is at the epicenter. Water and food insecurity are other internationally-recognized global risks; both are inherent to the problems the country faces and are deeply interlinked. Health security and the threats of emerging and reemerging infections loom large as global risks; Pakistan’s underreporting of H1N1 during the crisis in 2009 points to lack of responsiveness and hence failure on its part to comply with International Health Regulations, 205. It is easy to draw up an inventory of risks, but sobering to gain insights into the manner in which state capacity has been eroded over time to respond to these challenges.
In the economic sphere, global deliberations now centre on slow moving risks exacerbated by the financial crisis and global economic downturn, the costs and consequences of public bail outs, systemic loop holes in the global financial system, the impact of the crisis in making people risk averse which stymies recovery and the need for enhancing global resilience in a globally interconnected economy. Our worries in the economic sphere are sharper and fairly mundane. The grinding resource constraints and severely crowded out development budget are realities in an environment where there are many competing priorities: the unrelenting energy crisis, the cost of waging a war and fighting insurgency, the massive need for rebuilding in the aftermath of the 2010 floods, to mention a few. The deepening fiscal deficit and the new formula for federal fiscalism, which according to an expert economist “has sown the seeds of fiscal indiscipline”, inadvertently, I would add, are sobering. In such an environment, the lack of institutional resilience is evident in some key trends: in particular, the unrelenting inability of economic managers to implement the RGT reform, levy long overdue taxes on the ‘privileged sectors’ and address constrains that stand in the way of reforming public sector enterprises that continue to incur massive unnecessary losses from the fiscal system. Slow mobilization of development assistance and the stalemate over the IMF negotiations also mirror impediments to institutional resilience despite the presence of some credible economic managers within the system. These are ominous signs and indicate that injecting individual capacities in the system, though important in its own right, is not enough; a major overhaul of systems of governance is due.
While institutions may not be responsive and resilient, people are and have become so. They are enduring the fall out of the recession, bearing the brunt of unemployment, putting up with the crippling power shortages in severe temperatures, holding out in the face of food price inflation and soaring cost of utilities with painful and unprecedented endurance. The tacit suffering is now frequently changing color with street protests commoner than they were before. These outbursts can spark out of hand if institutional capacity to respond is not stepped up.
The recent notion and expectation that the 18th amendment and the 7th NFC will be a means of addressing these problems are founded on a well-conceived premise, but theoretically so. Decentralization of power to sub-state units can indeed open avenues for accelerating progress in social service delivery and enhancing public sector effectiveness by bringing those responsible for delivering services, close to intended beneficiaries and making them accountable. However, in reality provinces lack fiscal discipline and are plagued by pervasive collusion and state capture. The lack of progress in the accountability legislation and many other transparency promoting measures, prevailing views on the local government system, which resort to moving the pendulum towards strengthening provincial central control and away from district devolution and community oversight do not auger well for strengthening democratic governance in provinces. The risk of crony appointments and procurement graft will in all likelihood increase if checks and balances are not mainstreamed.
Institutional resilience with respect to individual and community risks is another important dimension. With many ministries related to the social sectors in the process of being devolved to the provinces over the next six months—inclusive of health, education, social welfare, Zakat, etc.—the mechanisms, which can enable that are in a flux. Perhaps the most ominous risk and one not very clearly appreciated in international circles is the risk that population trends pose in countries like ours. With a rapidly burgeoning base of the population pyramid, limited economic opportunities, and scarce welfare systems, there is a risk that people will increasingly fall prey to extremist ideologies.
Pakistan may not be the only country where the dark shadow of interconnected systemic risks loom and where the imperative to be institutionally resilient stands tall. However, it is certainly one of the few countries where the interconnectedness of risks and the progressive erosion of institutional capacity to respond are most clearly manifested. The pendulum of resilience must shift from individuals and communities to institutions and the state. People are stretched to capacity and may not be able to withstand stresses for very long.
The author is the founding president of the NGO think-tank, Heartfile. sania@heartfile.org
The vanishing ministry
Published in The News International on December 25, 2010:
The Implementation Commission of the 18th Constitutional Amendment is due to present its final recommendations to the Parliament for approval next week. Statements issued in the run up to that have already indicated that subsequent to abolishing the Concurrent Legislative List, a number of subjects, inclusive of health, education, rural development, population planning, social welfare, culture, tourism, youth affairs, etc., will be fully devolved to the provinces and their respective ministries will be abolished. As per the plan, their service delivery functions are to be devolved to provincial departments and their planning functions entrusted to the Planning Commission. Health is meant to be devolved in the third stage of implementation in July 2011.
This decision is part of a long-standing provincial demand and long over-due federal initiative to grant provinces their due share of autonomy. Devolving subjects to the provinces is also part of the drive to cut back establishment costs and reduce fiscal deficit, an objective, the International Monetary Fund has been actively encouraging Pakistan to pursue. In principle, grant of provincial autonomy has the potential to improve governance outcomes and strengthen Pakistan’s federal structure. Devolution of subjects referred to above is a needed step, but this doesn’t mean there is no role for the federal government in these areas. The decision of the Implementation Commission will introduce complex changes with far reaching implications for many sectors—this comment focuses on the health sector and the impact of abolishing Pakistan’s federal Ministry of Health (MoH).
Health has always been a provincial subject under Pakistan’s Constitution, even before the 18th Amendment. However, over time the federal MoH stepped into areas that were provincial prerogatives—in particular, the administrative tangle of controlling six tertiary care hospitals and several donor-supported and federally-led national public health programs. As a result, micromanagement and day-to-day operations overwhelmed MoH’s functionaries and the space for stewardship, normative and oversight functions, a core mandate of any MoH, got crowded out. The decision to recast the MoH in ways that frees it from these responsibilities was long-overdue and therefore to the extent of transferring these responsibilities to the provinces, provincial devolution of health is just the right step. However, this is by no means synonymous with doing away with the Ministry of Health.
Far from scrapping, ‘reconstituting’ and enhancing capacity of Pakistan’s MoH is an imperative. Proponents of the idea of scraping MoH may argue that these capacities can be built at the provincial level. These notions are mistaken for three reasons. One, the costs of doing so would be exorbitant; in fact, fiscal managers’ argument centred on using MoH’s abolition as a way of curtailing expenses would be self-defeating if the costs of creating parallel provincial structures is borne to bear. Second, capacity constraints, which currently prevail in the country, would make it almost impossible to do so. Thirdly, lessons from other countries with federating structures are instructive. Most have MoH and MoH-eqvivalent institutions, e.g., departments of state, which have clear and meaningful missions whilst corresponding institutions at the sub-national level technically have the ‘health mandate’. All countries with federal structures have ministers of health/secretaries of state, which represent them at the World Health Assembly every May in Geneva.
The principle goal of any MoH is to protect and promote the health and well being of its people. On the service delivery side, it is recognized that provinces have the right to organize and restructure the district health system along the principles of decentralization, local self governance and subsidiarity. The provincial mandate should be respected. However, there are a number of changes necessitated in Pakistan’s ailing Mixed Health System to achieve that goal. These entail complex reorganization and reform of existing institutions of service delivery and those that regulate them and provide oversight. This cannot be possible unless there is astute analytical and normative capacity within the system to oversee and guide the process of reform and ensure policy consistency. It would be next to impossible to try and create those capacities at the provincial level in today’s fiscally constrained environment. The federal government’s MoH struggled unsuccessfully with institutionalizing a National Health Policy Unit over a 10 year period with massive donor support; trying to do that in each of the 5 provinces would be an institutional nightmare and fiscally, out-of-the-question. There are other reasons why MOH’s existence and enhanced role are needed. In today’s world, the threat of emerging and re-emerging infections has made disease security a point of convergence for global health. Pakistan has performed abysmally with respect to ensuring compliance with International Health Regulations 2005, a WHO-negotiated global inter-governmental treaty. This was confirmed in the under-reporting of H1N1 last year and evident in many cases previously. Pakistan does not have an integrated disease surveillance system or an apex coordinating arrangement to collect, consolidate and analyse health information. MoH’s role in these areas is a strong rationale for building its capacity further—far from abolishing it.
The complex inter-country dynamics around trade in health—centred on human resource migration, consumption of medical services overseas, commercial presence of a foreign service provider in the country—demand critical institutional oversight. With health services and human resources not featuring as a separate item on Pakistan’s National Trade Policy, there is a risk that the provinces will be left in the lurch with no capacity to deal with these issues if the MOH is abolished.
For whatever it was worth, the latter is an institutional oversight mechanism mandated to deal with this area. A similar concern applies to the growing notion of enterprise development as a means of achieving public goals in health, an area which needs to be carefully regulated.
There are many other areas where central coordination on behalf of the provinces by the Ministry of Health even in the scenario of enhanced provincial autonomy can spare provinces from unnecessary duplicative work for which they neither have human resource capacity nor the institutional arrangements in place. Other than normative functions, economic coordination with donors and bulk procurement of medicine and supplies where cost saving can be achieved, and medicines and human resource regulation fall in this space. Currently most arrangements, the Central Licensing Board, Drug Regulatory Board and the Drug Appellate Board exist at the federal level whilst Quality Control Boards exist at the provincial level. It would be an unnecessary duplication to try and recreate the former category, provincially.
In a nutshell therefore, there are many justifications for the need to reconsider the decision to abolish the Ministry of Health. Having said that, it is also critical that the mission and mandate of MoH is re-casted so that it divests itself from roles that lead it away from its core functions and builds its capacity in normative, analytical, regulatory and oversight tasks. There is need for bridging MoH’s personnel deficit and addressing systemic constraints that plague its functioning. Without attention to strengthening normative capacity alongside provincial and district devolution of health, there is a risk that the current mayhem within Pakistan’s health system will be exacerbated and the ability of the state to deliver health services to its people will be further eroded.
The author is the founding president of the NGO think-tank, Heartfile. E-mail: sania@heartfile.org
The PDF premise
Published in The News International on November 22, 2010:
Pakistan Development Forum (PDF) 2010 was convened at a time of unparalleled challenges—with several macroeconomic issues, a grinding fiscal crunch, competing priorities for resource allocations, an energy crisis, ongoing war, relentless insurgency, and an unprecedented need for resources in the aftermath of the worst disaster on this planet in recent history, characterizing the country’s needs. Within this context, pronouncements at the forum highlighted some windows of opportunity at the margins of these significant challenges. This comment alludes to six in particular, emphasizing that stronger stewardship is needed to reap the potential within these opportunities.
The first is about development assistance itself, given that PDF is the key forum, which determines priorities for allocating development assistance in Pakistan. In this regard, commitment of the international community to express their solidarity with Pakistan is appreciable, specially since many donors are recovering themselves from the ravages of a recession and have many competing priorities at home for which they are answerable to their taxpayers. Commitments have been made despite donor fatigue and we hope pledges will be realized.
Let us not forget though that both donors as well as Pakistan’s economic managers need to learn lessons from past mistakes in relation to the use of development assistance. During the past three decade-long surges in aid (1960s, 1980s, and 2001 onwards), use of aid as a foreign policy tool by donors and the lack of attention on part of successive governments to use aid strategically for productive assets that could generate resources necessary to pay back loans and the use of resources in ways that contributed to dependency were major mistakes. In this regard, there are many immediate questions in view of the commitments being made to provide assistance “on budget”. Aid is flowing into Pakistan under various policy and contractual norms and instruments under the rubric of grants, humanitarian, military and development assistance and debt-swaps; it is imperative that these are strategically harnessed.
Secondly, on a positive note, there appears to be an emphasis on systemic reform and on the need to tackle corruption alongside discussions on aid and revenue mobilization. However, the importance of transparency promoting reform in terms of structuring a set of institutional parameters needs to be clearly spelt out. Tackling corruption should not be about a set of coercive politically motivated and individually targeted measures, as has generally been the case in Pakistan under various administrations. It should be about institutionalizing systems and structures, which eliminate opportunities in the first place. Work on such structures was initiated in the past on several occasions but could not be sustained and therefore, wasn’t fully institutionalized. The lack of commitment within the system to sustain reform is an important constraint in this regard. Incoming governments in Pakistan have the tendency to undo programs initiated by past governments in the interest of political expediency without regard for the value lost in the process. This trend has been detrimental for some of the projects which could have helped strengthen processes and systems of the executive with reference to building anticorruption safeguards. There is an opportunity to accord higher priority to this now in view of increasing demand and the consequent support that this is likely to get from various constituencies. The recent advent of judicial activism around anticorruption, an open media which is playing a pivotal role in highlighting institutional fault-lines and unearthing scams, the potential that exists to partner with civil society in the calls for greater transparency, and donors for whom transparency has become a sine-qua-non, particularly with reference to the use of Kerry Lugar resources, are notable in this regard.
Thirdly, it is a sign of responsibility that Pakistan is taking proactive steps to mobilize indigenous resources through the reformed GST, finally announced at the PDF. Although the government’s economic managers have capacity to technically plan this reform and there is acceptance of the approach by technocrats in opposition factions, the street and political sentiment will not be supportive, businesses that come within its net will fight it tooth and nail and the reform may become a subject of political point scoring. Opposing political factions are already pointing in particular to the lack of attention to widening the tax net and taxing the exempt sectors and the rationale behind committing to the IMF without the parliaments approval, which reinforces the impression that the parliament is, in effect, a rubber stamp. It is important that the government takes the public into confidence about the imperatives for this levy, the circumstances under which it was negotiated, the constraints, which led the economic team to commit without the parliaments approval and measures which are being taken to ensure that the common man and the poor are outside of the remit of this levy.
In the fourth place, it is encouraging that expenditure management and fiscal discipline were recognized as mainstream concerns at the PDF. Establishment of the committee on budgetary oversight, stipulations governing supplementary grants, and an amended State Bank Act which places limits on government borrowing, are positive steps indeed. However, ensuring compliance with such stipulations in an environment where circumventing procedures has become a norm will be a challenge. It is also a welcome trend that economic managers themselves are talking about the massive Rs. 623 billion loss from public sector enterprises, and are tabling plans to cut back expenses in that arena through various policy choices. These reforms will be painful indeed as massive lay offs may be necessitated and it remains to be determined how that can come about in a context where the government is resorting to massive job reinstatements in these very organizations through legislative enactments in the name of upholding employees’ rights citing past layoffs as victimization.
Point five relates to the importance of mainstreaming the role of provinces in the process of development and getting them to own their development agenda, which is just the right step after devolving responsibilities in the provincial domain under the 18th constitutional amendment and the new federal fiscal formula. But expectations have to be tempered by the realities of provincial stewardship capacities and fiscal discipline and knowledge of the fact that provincial competence in the area of agenda setting, determining priorities and visionary planning are weak. These critical gaps in capacity will have to be bridged as a priority.
Lastly, one understands policymakers’ preoccupation with big ticket issues in grapping with the macro economy and getting it back on track. Those of us with interest in social outcomes do understand that the benefits of broad based growth in accruing social benefits far outweigh the advantages of isolated social sector piecemeal interventions and are, therefore, supportive of attention to these areas. Nevertheless, the lack of attention to the social sector, per se, from a programmatic standpoint in this year’s PDF has been glaring. It is hoped that due attention would been accorded to areas that need reshaping in view of the recently reorganized landscape of social sector related responsibilities in Pakistan’s federating system and that some long overdue critical policy decision would soon be made in this space.
The author is the founding president of the NGO thinktank, Heartfile. sania@heartfile.org
Dengue – fears & imperatives
Published in The News International on November 06, 2010:
The recent outbreak of Dengue, which is commanding widespread attention, is an important insight into several health and overarching governance issues. Before those are alluded to, a brief comment is offered on the current situation. It is indeed a sign of progressive attention to welfare that hotlines, round the clock media coverage, front paper trackers and policymakers’ responses and reprimands have been galvanized in response to a public health concern. 4,363 cases of suspected Dengue Fever have been reported in Pakistan with 2,062 confirmed cases and 15 deaths until 22nd October 2010. Let’s be reminded though that in the same country, hundreds of thousands of infants and mothers die needlessly every year; tens of millions suffer from hypertension and diabetes. If proportionate attention and resources are allocated and if decision-makers’ wrath and intolerance is energized in response, achieving health goals might become a pragmatic reality rather than an aspirational vision, which is what it is today.
Let us also recall some facts about Dengue in terms if it being a public health threat to put things in perspective. There appears to be a fear ingrained amongst the general population in this respect, which is somewhat out of place. It should be appreciated that 2.5 billion people, two fifth of the world’s population, are at risk from Dengue. Estimates show that 50 million cases of Dengue occur worldwide every year with the disease being endemic in over a hundred countries with many yearly outbreaks. The present outbreak appears to be the worst in Pakistan, but it is also important to communicate that the disease does not spread from person to person. Moreover it is usually a self limiting febrile disease and serious complications, such as fall in platelet count (a type of blood call) are a complication only in a minority of cases. Furthermore and fortunately, its vector (the mosquito) will not be able to survive and breed in the forthcoming winter season and hopefully the outbreak will be contained soon.
In contrast, many other equally serious infectious diseases (such as Multiple Drug Resistant Tuberculosis) often go largely unnoticed by the general public and decision-makers as they do not produce explosive epidemics. The salience of these points is being underscored to allay public anxiety, whilst stressing that the emphasis on public awareness and the public health response should be maintained.
Importantly however, the outbreak presents an opportunity to review existing constraints in Pakistan’s health system. The importance of three points is being underscored in regard.
The first relates to disease surveillance. Karachi and Sindh are reporting higher numbers as they have a working surveillance system already established for Dengue. There have been no reported cases from Balochistan, which is indicative of weakness in the disease surveillance infrastructure. Underreporting was also a serious concern during successive outbreaks of Avian Influenza during the last few years and Pandemic Influenza A H1N1, last year. Underreporting is indicative of failure on part of Pakistan to fulfill International Heath Regulations 2005, and is evidence of critical issues with Pakistan’s health information system. Currently there are around 15 disease information collection systems in place, inclusive of surveillance systems for the following diseases: Acute Respiratory Infections, AFP/Polio, Bacterial Meningitis, Diarrhea, Hepatitis, HIV/AIDS, Malaria, Measles and Tuberculosis. In addition, there is the Disease Early Warning System (DEWS), which is being used in the flood affected districts, the Expanded Program for Immunization’s system and the Health Management and Information System (HMIS). Many of these surveillance systems are discrete, horizontal, fragmented and are dependent upon external donor support. Pakistan does not have an integrated disease surveillance system. Within this context, the Prime Minister’s signaling of intent to prioritize the establishment of Integrated Disease Surveillance and Response (IDSR) on November 4 is a step in the right direction. Momentum must be sustained to overcome programmatic turf hurdles that stand in the way of creating such a structure.
In addition to this fragmentation, some surveillance systems are also antiquated and have not benefited adequately from technology. For example HMIS, a nationwide system of collecting data from public first level facilities, has not been fully automated. Therefore, the potential that exists to leverage Pakistan’s telecommunication boom and create a central computing facility for the public and private sector to report into remains untapped. Thirdly, there is no agency clearly mandated for collecting, collating and consolidating and relaying information and data. Now that a new role for the Ministry of Health is being crafted in the post-18th Amendment scenario, due attention should be accorded to health information as one of its mandates. The cost of inattention could be enormous in the event of another outbreak of Avian Influenza in Asia.
Secondly, problems in health systems functioning merit attention. Punitive actions of provincial authorities to compel staff accountability are a reminder of the pervasiveness of absenteeism from public health facilities and the manner in which functionaries use the public job leverage to boost private practices. Signaling of intent by the government to provide free care to those that have been affected, while admirable standalone, drives home the realization that more than 74% of the population of the country pays out-of-pocket to access care—the most regressive means of health financing—and that financial risk protection for vulnerable communities hasn’t been secured. The plight of patients in health facilities is indicative of dire quality issues. Health systems constraints in wake of the Dengue outbreak are paralleled with allegations of procurement graft and accounts of pilferages from the supply chain in medical relief operations for flood affected areas. All these point to the need for fundamental reform of the health system.
Thirdly, the country’s constrained research capacity has also been brought to bear. We do not know, for instance, if mosquitoes have developed resistance to the insecticides currently being used for fumigation, or if the current mode of fumigation is effective. Evidence related to the extent of contribution of the recent floods needs to be examined in detail with reference to the impact of climate change on the environment, vector habitats and consequently disease patterns in Pakistan. Furthermore, we also need to analyze if lack of attention to the local government system and the current polarization has affected attention to water and sanitation infrastructure in ways that promote breeding grounds for mosquitoes. Many disease outbreaks and public health problems have little to do with constraints in the healthcare system but can be tracked back to broader socioeconomic determinants, which have a bearing on the local government system. It is only with a critical analytical lens and appropriate institutional capacity that the long term consequences of these and many others issues and questions can be deciphered.
The author is the founding president of the NGO thinktank, Heartfile. sania@heartfile.org
The budget process
Published in The News International on October 23, 2010:
Drawing attention to the budget process during the month of October may appear a little out of step specially when there are so many other governance-related storms whipping. A closer look however indicates otherwise. The budget process for a fiscal year starts in the month of October with the Ministry of Finance issuing budget calls to all the ministries and departments seeking detailed reports of expenditures and estimates of demands for grants. Subsequently, the standard momentum takes course with the process coming to fruition in June with the budget’s presentation in the National Assembly. Rallying cries to reform the budget process when the process itself is well underway doesn’t allow space for change. If change is being advocated for, now is the time to reiterate its importance so that the new parameters can be shaped in time.
The budget process and the budget itself are critical this year round. Pakistan’s grinding fiscal crunch in the face of many existing competing priorities has been compounded by the unprecedented need to divert resources in the aftermath of the floods. Using the budget as a key instrument to signal the government’s priorities is therefore an imperative in the face of these constraints.
Over the last few years a number of gaps have been pointed out in the existing budget process. Of these the most critical is lack of effective engagement of the parliament in the budget making process. There is a huge paradox evident in this. The budget is the most important piece of legislation, but legislators feel disempowered with respect to their role in this process. The parliament is almost a rubber stamp when it comes to the most important law. There are many determinants of this practice, of which process limitations—a factor amenable to reform—is one. Last week the Pakistan Institute of Legislative Development and Transparency (PILDAT) released a Budget Process Guide, a capacity building tool, which is worthy of being commented on within this context. The guide bases its recommendations on a review of case studies in other countries, which have some level of institutional similarity with Pakistan’s system with reference to its budget process. Insights from case studies on Turkey, Canada and India’s budget process have been triangulated with an in-country analysis, which draws on stakeholders’ views and process analyses conducted by the organization over the last one year. Recommendations have the potential to increase the space for parliamentary engagement in the budget making process—increasing the duration of the parliamentary budget process from an average of 10 days at present to 60 days, active engagement of parliamentary Standing Committees, empowering the Finance Committee to conduct pre-budget consultations with stakeholders, creation of technical capacity at the parliamentary level for independent budgetary review and scrutiny of the defense budget, are the key recommendations.
The case study from Canada provides some useful insights for implementing these recommendations. For instance, it reaffirms the importance of engaging parliamentary committees but cautions that specialized committees with broad mandates should preferentially be engaged as opposed to departmental committees, which might have a problem separating assessment of budget estimates from their regular ongoing work involving oversight of departmental policies and practices. The Finance Committee’s role has been regarded preeminent in the Canadian budget process system in terms of spearheading pre-budget consultations and engaging civil society stakeholders in this process—an insight relevant to Pakistan. Indeed one of the recommendations draws insights from this and calls for creating a sub-committee of the Finance Committee on budget issues. Such a structure must be complemented with grant of mandate to engage civil society actors, allowed sufficient time to hold pre-budget consultations and supported with efforts in parallel to build technical capacity within the parliament to conduct independent budgetary analyses. The latter has been captured in the recommendations in the call for creating a ‘budget unit’. The Canadian experience has some valuable insights with reference to the latter, which can help avert turf rivalries.
Reform of the budget process must also create space to involve civil society stakeholders. As entities organized around shared interests, purposes and values, they can be an important countervailing power to the state. Think tanks, policy institutions, NGOs, professional associations, communities, activists, support groups, volunteers, social enterprises, trade unions, cooperatives and academia can help set intra-sectoral and inter-sectoral priorities and strengthen analytical ability.
By allowing more time and meaningfully engaging all stakeholders, the budget process can be made more participatory and transparent. However, rigor at the process level needs to be applied all year round with engagement of FBR, Budget Wing of Ministry of Finance and parliamentary committees, given the strategic significance of the budget as being reflective of country plans. It must be appreciated that the objective of parliamentary engagement should be to help overcome certain fundamental budget anomalies, which are currently pervasive—and it is within this context that many questions emerge.
Would the parliament, currently dominated by the elite, subscribe to the notion of taxing certain elite sectors and broadening the tax net while those that benefit from the current policy sit in the parliament and continue to wield great influence? Would the influence exercised through political party finance come to play in deliberating on such issues? Would they support easing the burden of indirect taxation which hurts the poor, which virtually have no voice in the parliament? Would the tax evaders in the parliament support policy changes that are meant to address the loop holes that they exploit? Would the parliament support tough decisions that relate to reforming/privatizing public sector enterprises, when this may entail thousands of their party workers loosing jobs, while they are on their way to massive retrospective reinstatements on the other hand?
Would parliamentarians be committed to supporting allocations for procurement reforms, judicial reforms, transparency building measures in public finance management, actions for checkmating cartel activity, when it is precisely these gaps in the system that are exploited by some non-bonafide elements within the political system? Would parliamentarians have the capacity and commitment to act as honest brokers, make a meaningful contribution in exercising oversight so that fiscal discipline is ingrained, debt remains within manageable levels, aid is used to build productive assets, development assistance doesn’t become fungible, and mini-budgets and development cuts don’t erode away the budget as the year passes?
As parliamentarians get drawn into the budget process—as they should—these questions will become part of the armamentaria of accountability parameters. There are some sane, progressive, liberal voices and clean hands in the parliament, which can join forces for change. With the media and civil society on their side, there might be place for hope.
The author is the founding president of the thinktank, Heartfile. sania@heartfile.org
The flood and disaster observatory
Published in The News International on October 02, 2010:
In the last eight weeks, ‘coordination’ has come to be viewed as the epitome of flood relief, and the lack thereof, a major failure of stewardship agencies. The emphasis on coordination in the given context is not without reason. The massive need for response that the flood has generated, coupled with grinding fiscal constraints, create an imperative to minimize duplications and maximize synergies. Whilst the need cannot be overemphasized, it is the approach to coordination that needs to be placed under the analytical lens. What do we mean by better coordination? What should it achieve? What are the difficulties, which stand in the way of enabling that? Do we have structures to build upon? And where are the existing competencies and institutional arrangements?
In relation to the first question, one thing to note whilst making a case for optimizing coordination is to take stock of existing arrangements. There are a plethora of coordination arrangements already in place. The armed forces have their own system, the donors led by UNOCA have likewise, as do the National Disaster Management Authority (NDMA) and several provincial agencies. Civil society has its own mode of collaborating.
There are coordination arrangements within individual sectors, in addition. The health sector, for example, has a health cluster, themed task forces, and mobile teams in the field, a mechanism for operational control of field and mobile hospitals, and some level of oversight over fixed facilities; they publish a bulletin, maintain a website, provide for linking volunteers and have a mechanism for inter-cluster coordination. Other sectors have analogous arrangements. In addition to interagency coordination intra-sectorally, there are some mechanisms in place for inter-sectoral coordination. What exactly do we mean by enhancing coordinating then?
Most references to coordination in the present context refer to a supra-organizational structure or mechanism. In terms of what it should achieve, a number of objectives are noteworthy. Synchronization and integration of activities, minimizing duplication and wastage, ensuring efficient use of resources, and harmonizing civil society and volunteer contributions with the states’ response, are to mention the important ones. The latter is important since volunteers are generally first on the scene in disaster situations, as also outlined in Resolution 56/38 of the UN General Assembly. The massive mobilization of individual volunteers and organized civil society in wake of the recent floods is evidence of the need to develop a mechanism to harness their potential.
There are many difficulties, which stand in the way of creating a supra-organizational coordination structure, which can achieve these objectives given the extremely broad landscape of actors involved in disasters. Agencies have varying mandates, missions, and objectives and diverse administrative and reporting relationships. When they are asked to synchronise, share information and come under the control of another structure they fiercely guard their turf and independence. Coordination cannot be aligned on vertical principles, when agencies don’t have reporting hierarchical relationships.
The command and control model of coordination often perceived as the ideal mode of engagement doesn’t appear feasible as agencies have a disincentive to participate in such an arrangement. Any supra-organizational coordination structure, therefore, has to offer two things to be successful. One, it has to offer incentives for agencies to participate, and secondly, it should add value to what the existing arrangements have to offer.
It is in view of these two prerequisites, that the idea of a Flood and Disaster Observatory is being mooted in this comment. The word ‘observatory’ is conventionally used to describe a location for observing terrestrial and/or celestial events. There are many examples of disciplines for which observatories have been constructed; these can be ground, radio, web, space or air-based.
The proposed Flood and Disaster Observatory is envisaged to be a dynamic user-friendly web-based portal/interface. Such an interface can enable information to be updated in real time about the needs of various geographic regions and the agency commitments and actions in response. It would also enable assessment of gaps in the field and outline requirements.
In discussing this idea with a technical colleague, certain technical aspects became clearer. If the system is to be brought in immediate use then a simple database application, where the data is entered in forms and rendered in tabular reports with the help of built-in queries, can be implemented in a matter of a few weeks. However, the ideal solution would be to provide a user-friendly interface, where the user could click on a map and drill down to the level of the Tehsil and then enter the requisite information. An even higher level of sophistication would be to make use of a GIS-based system such that the information is not only entered with the help of a graphical interface but it can also be rendered visually on a map. A GIS-based system works off the same database hence no additional information is provided but the visual display superimposed on a map helps in quickly identifying the target location where the specific type of aid is to be provided. A visual map also provides better context and makes it convenient to see the status of the neighbouring areas rather than having to rely on successive queries.
Any system, whether GIS-based or a simple database application, would have to provide a mechanism for authenticating users. It is this system of information and authentication, which can enable coordination implicitly. Real time updating, interaction, and visibility would be an incentive for agencies to participate; and since the mechanism would not be coercive it would be acceptable to most stakeholders. It would also make perfect sense given Pakistan’s excellent telecommunications infrastructure.
The strength of this approach also lies in the fact that state agencies are already working with something that can be a stepping stone to developing this. For example, the flood relief pages of NDMA, and PDMA’s websites have many useful features; they post regular weather forecasts and flood warnings and information about relief camps and urgent needs. Punjab DMA has information for registering NGOs and volunteers and has many active features related to flood relief. The inclusion of interactive features for updating the information dynamically from a variety of sources can significantly enhance use of the web-interface for enabling agencies to use it as a common platform for coordination, hence maximizing synergies and minimizing duplication.
Pakistan must enhance its capacity to cope with disasters. Unfortunately, the country is amongst the top twenty global warming hotspots in the world with low adaptive capacity. Findings of a vulnerability mapping of Pakistan clearly indicate that “climate change will increase the variability of monsoon rains and enhance the frequency and severity of extreme events such as floods and droughts”. In attempting to prepare ourselves for next year, cost effective strategies as the one being proposed offer value. The government could convene technical experts to explore its feasibility further.
The author is the founding president of the NGO think-tank, Heartfile. sania@heartfile.org
Innovative flood-financing
Published in The News International on September 22, 2010:
Financial constraints, which parallel the unprecedented need for financing to rebuild and rehabilitate in the aftermath of the recent floods are calling for efforts to mobilize resources to bridge a huge gap. Currently, several conventional channels are being utilized and explored further to achieve that objective. There have been public pronouncements to the effect that the Public Sector Development Program (PSDP) will be radically reshaped with priorities for reallocation of development resources redefined and that a reformed GST will be levied with effect from October 1 to bridge the fiscal gap. Beyond humanitarian assistance, which has come in from conventional and other, local and international sources, international development actors have been mobilized. Bilateral sources have made some pledges with major chunks of support inflowing in-kind. However some have realigned priorities within existing committed envelopes towards flood rehabilitation and relief. A number of soft loans and multilateral grants have been announced, but above all, the contributions of individuals have been colossal in terms of support of every conceivable nature.
But the scale of the devastation is just too massive and the resource-need far too large for conventional sources to fulfil, as a result there is shortfall, which will become more apparent as the damage needs assessment is completed. This creates an imperative to explore innovative approaches for generating, targeting and utilizing resources. Three points are being articulated within this context.
The first relates to innovative means of revenue generation. A few examples from the policy sphere of health are being highlighted to underscore the relevance of out-of-the-box solutions. For example, international experiences show that a very small earmarked indirect tax imposed on specific products or transactions can raise significant revenue. Although it is accepted that in Pakistan, with very high indirect taxation, an adverse ratio of indirect to direct taxes and plans to levy the reformed GST underway, the idea of an ‘earmarked flood tax’ could be met with resistance. But the key element in the kind of indirect tax being referred to herein is the very low charge. Such taxes are imposed on specific products or transactions and are collected by the retailer and forwarded to the taxation authority. There are many examples around the world where such taxes have been considered as humanitarian contributions and have provided significant resources. For example, Brazil’s CPMF, a tax on bank account transactions set at 0.38%, and levied on paying bills online and major withdraws raised an estimated US $ 20 billion per year and provided funding for 87% of the funding for the government’s social protection program (Bolsa Familia) before it was voted down. Similarly a solidarity contribution or ‘tax’ on airline tickets represents 72% of UNITAID’s financial base. This was initially introduced in France. As of today, 13 countries have implemented the tax and others in the process of joining. UNITAID attests to the fact that an international solidarity micro levy is well accepted by the public and causes no economic distortion. Countries have also been exploring the feasibility of a ‘digital’ or a ‘bit’ tax, which involves a charge on traffic over the internet.
Voluntary business and consumer contributions are another innovative means of mobilizing resources, and can be a source of flood financing. These are donations made by individual consumers and operate in different ways. In one model there is voluntary linking of a donation to the payment for a service (e.g. payment of mobile phone bills or payment of income tax); in other arrangements these can be automatic. Voluntary contributions have less certain funding streams than a tax, but once established are reasonably predictable.
Similarly, financing innovations can also be relevant to debt relief. The latter is increasing becoming a rallying cry, especially in the case of organizations and individuals associated with the Campaign for the Cancellation of Foreign Debt. However such ideas should ideally centre on an appropriate instrument. For example, debt relief has previously been enabled in Pakistan through the Poverty Reduction Strategy Paper instrument, on the condition that the freed up resources were used for poverty reduction. Similarly, Pakistan has been part of Debt2Health, an initiative, of the Geneva-based Global Fund to Fight AIDS, Tuberculosis and Malaria (GFATM), under which the German government relinquished the right to partial repayment of loans on the condition that Pakistan invests the freed-up resources in approved programmes of GFATM.
Insights can also be gained from the financing arrangements within the health sector’s global product development partnerships (PDPs). PDPs operate on a not-for-profit basis and as ‘quasi venture capital funds’ in the domain of developing world health. They raise funds from a wide range of public and philanthropic sources, select the projects that offer the likely highest health return for investment, and closely monitor and manage the progress of the portfolio they have invested in. As a result, they act as a major consolidator of public funding, of investment risk, and of global coordination in their given field. Given the need to tap into private sector resources, some useful lessons can be gained from these experiences in the current scenario particularly with reference to the construct of the multi-donor trust fund which donors appear to be working towards. A ‘partnership fund’ can enable harmonizing and coordinating aid and pooling aid in support of a particular strategy, the fundamental premise enshrined within the Paris Declaration on Aid Effectiveness. It could also harness the potential within philanthropy in Pakistan’s indigenous context.
Secondly, there should be a renewed focus on infrastructure financing through the public-private route. Even before the flood, this had become essential due to the gap between the need for infrastructure investment and the fiscal space within PSDP, which allowed this. After the flood, the huge need to rebuild infrastructure at a time of great fiscal crunch makes this approach one of the few viable options. However, not all projects will be commercially viable. The government’s PPP institutional machinery, the Infrastructure Project Development Facility, can be useful in ascertaining viable options.
Thirdly, a financing instrument, which can enable and enhance the government’s capacity to deliver services through purchasing services from and contracting the private sector, is important. Purchasing is an important policy tool for Pakistan as majority of services are provided by non-state entities in any case. These private sector entities can be an important stakeholder in the process of rebuilding, particularly in the area of health and education as the infrastructure in these two areas has been destroyed in the flood hit areas.
The deep social pain that this crisis has inflicted can only be eased with an unprecedented response, for which resources are critical. Innovative solutions offer an option to mobilize additional resources. Whilst these options exist, their application in Pakistan will depend on the government’s capacity to plan in the local context and implement in an environment where there are many systemic constraints. There are many challenges in implementing the taxes being referred to herein as they may not necessarily appeal to politicians and consumers and may require complex legal changes and ongoing regulation to ensure compliance. The success of infrastructure PPP’s depends upon fiscal and legal prudence of the government and their ability to build safeguards and share risk in a manner that is mutually beneficial, both to the public and private sectors. Likewise contracting-out necessitates a new set of institutional norms and regulatory frameworks. Although these challenges appear daunting, they can be overcome with careful evidence-informed planning and the right institutional competencies. The need to think out of the box has become imperative in the post-flood situation; the gap is just too large for conventional sources to bridge.
The author is the founder and president of the NGO thinktank, Heartfile. sania@heartfile.org
Disaster governance
Published in The News International on September 04, 2010:
Disasters are a true litmus test of governance. Many attributes of governance interplay in disasters, before, during and after a situation. This comment flags five governance lessons, evidenced by the response to the recent catastrophic floods.
The first attribute relates to strategic planning, which raises an important question: was it possible to predict the behaviour of the monsoons this time round? Whilst it is true that the scale of the disaster could not have been predicted, the calamity clearly hasn’t dawned as a surprise.
Findings of a vulnerability mapping of Pakistan as part of a regional study on global environmental issues sponsored by the Asian Development Bank had described the potential effects of climate change on natural resources as far back as 1994 and had suggested strategies to avoid worst impacts. This was also emphasized in the South Asia Human Development Report in 2007 and was reiterated by the report of a Task Force on Climate Change, established under the aegis of the Planning Commission, in February 2010. The latter stated “it is projected that climate change will increase the variability of monsoon rains and enhance the frequency and severity of extreme events such as floods and droughts”. International reports have placed Pakistan amongst the top twenty global warming hotspots in the world with low adaptive capacity. It is not clear if these forecasts led to institutional changes to enhance capacity. Pakistan also doesn’t have a national security apparatus in place which takes cognizance of human security threats that can be precipitated as a result of forecasted disasters, with implications for economic, food, energy, community, individual and health security.
Relevant to the case in point, the metrological office had issued an advisory on June 26 that there would be an increased risk of flash floods. It isn’t clear why the country’s disaster management apparatus wasn’t shaken into action in response to this forecast.
Secondly, this should be an opportunity to explore if the country’s disaster management frameworks developed subsequent to the October 2005 earthquake are optimally functioning and the weaknesses in the operations of the Flood Relief Commission. Ideas are being mooted to create new commissions and institutions without fully realising that the top down model of centralized bodies and installation of parallel structures doesn’t work unless certain governance norms are ingrained. The government must take stock of the existing governance constraints these institutions suffer from and be clear about the manner in which it envisages obviating these in new arrangements. Rather than parallel structures an oversight body may be more appropriate, an option the government is also currently exploring. However, unless the arrangement is mandated with key prerogatives related to scrutiny and accountability, not much will be achieved.
Third, governance of the Indus River and the politics that plague it is a subject in its own right. ‘Kalabagh politics’ is a classical example of how political expediency interplays in strategic governance decisions. The entire nation is being reminded today that if some strategic dams existed, the scale of devastation would have been much less. What the nation forgets though is that it is the lack of entrenchment of accountability—a governance norm—which manifest itself as inattention to strategic decisions such as the creation of dams.
Inefficiencies and collusion in regulating the Indus River and the ill planned settlements around it have also come to the fore. The ‘politics of canal and flood embankment breaches and’ diversion plans are an illustration of how power is abused, systemic protocols are disregarded and political influence is wielded. Spontaneous unexpected collapse of the embankments raises many questions about the quality of infrastructure and the interplay of collusion and rent seeking in the process of awarding contractual agreements. It is ironic that our perennial dilemma centres on water insecurity, with crippling energy shortfall a consequence, despite the existence of waterways whose potential we haven’t harnessed by increasing our storage capacity and innovative water management.
In the fourth place, there is a strong interplay of governance in many short term priorities. Coordination is critical at every stage. Pakistan’s indigenous population and diaspora have stepped in to help as has the international community. Unfortunately, the country does not have a regulatory framework in place to allow full expression of the potential contribution of volunteers nor does it have frameworks that can enable civil society engagement in a structured manner. It is critical to develop institutional mechanisms, so that Pakistan can leverage the strength of many strong civil society organizations and the socially committed private sector, which have been mobilized in response to the crisis.
Resource management is another problem. It is hoped that support commensurate with the findings of damage assessments—currently underway—is mobilized and that attention is accorded to debt relief. However in order to tap its potential Pakistan will have to institutionalize oversight mechanisms in order to overcome the current trust deficit, which plagues its relationship with some aspects of donor interaction and as a result of which disbursement channels outside of government entities are now being explored.
Other short term priorites include consolidation of information streams in every sector—health education, infrastructure, livelihood, etc., so as to obviate current duplication and multiple channels of information flow. In the short term the government of Pakistan must also facilitate speedy import of essential food items so that cartelization, which has been a dominant determinant in the recent commodity shortages in the Pakistan doesn’t factor into play to exploit the situation.
In the fifth place and in the medium term once relief is over, the task of rehabilitating the victims of a vast humanitarian tragedy and economic revival must get underway. Plans for reviving industrial and agricultural output, rebuilding infrastructure, and supporting poor communities in a post-disaster situation will have to be developed and implemented. This cannot be enabled unless there are additional resources, which are effectively utilized. Diversion of low priority expenditures, a focus on aid effectiveness, cutting back establishment costs has become an imperative. The critical question of increasing Pakistan tax-to-GDP ratio and policy discussions on reform of GST becomes relevant, now more than ever.
Pakistan has been hit by this calamity when there are other mammoth tasks at hand. The calamity has hit at a time when the country is grappling with many competing priorities. The internal security situation is unpredictable, a war is ongoing and fiscal constraints are grinding. There is lack of clarity in governance norms at the overarching level as many things are being reshaped. The federation’s relationship with its provinces is being redefined under a constitutional amendment and a new formula for fiscal federalism. Drastic changes have been made in the local government system. Many processes are therefore, in a flux. The country therefore has to grapple not only with the immediate disaster at hand but also the systemic processes, upon which successful relief and rehabilitation is dependent. Success is heavily dependent on the quality and effectiveness of governance. It is not just the lives and well being of millions of people in poor riverside communities at stake, but a lot more this time round.
The author is the founder and president of the NGO think-tank, Heartfile. sania@heartfile.org
Child protection legislation
Published in The News International on August 17, 2010:
The Khyber Pakhtunkwa Child Protection and Welfare Ordinance 2010 is due to be presented to the Provincial Assembly any time now. The Ordinance is meant to be an improvement on the previous legislative enactments. However, a recent review circulated on a virtual civil society network by an NGO working in the area of child protection has raised some valid points about the Ordinance’s technical and normative weaknesses—in particular its lack of conceptual clarity in relation to corporal punishment, the divergent stances signalled as regards its abolition and restrictive definitions of sexual abuse and trafficking. Whilst acknowledging that the new Ordinance provides comparatively high protection than the existing criminal protection system for juvenile convicts, the review argues that the law fails to raise the minimum age of criminal responsibility which is currently 7 years. What is worrying, as noted by the review, is that the extensive feedback on the draft law, solicited from the civil society over the course of several years whilst the law was in draft shape hasn’t been heeded to at all.
The Ordinance needs to be viewed in a broad context. There are many complex issues that need to be addressed in relation to the state’ responsibility towards children and the manner in which they should translate into norms. It has been 10 years since Pakistan has ratified the United Nations Convention on the Rights of Child (UNCRC) but the domestic legislation that had to be enacted to translate that commitment into law has been long overdue. UNCRC categorizes the state’s responsibility towards children in four streams—survival, protection, development and participation. The KP Child Protection and Welfare Ordinance 2010 relates mostly to some aspects relevant to one stream, namely protection.
The need for provinces to pay heed to legislation in this area has become important after the 18th Amendment, as the subject of child welfare has now come totally under their purview. There are many complex legislative issues under this rubric. Some of these are covered under various federal laws. Provinces should now start thinking about how they can promulgate provincial laws in all these areas within the one year period given to them in the transition time window. The risk being that at some point federal laws can be challenged since the area is no longer in the federal domain. Two areas are important for legislation in this connection.
One pertains to the broader question of the Rights of a Child. The need to spell out the rights of a child is important since the Constitution does not explicitly refer to this subject.
It might be useful to look back into history to examine past attempts at framing norms in this area so that provinces can build further on these frameworks. One of the most relevant within this context is the Child Rights Bill, which was introduced in the National Assembly as a private member’s bill on April 14, 2009. The bill was drafted in the light of provisions of UNCRC. After going through the due process involving Parliamentary Committee deliberations and Ministry of Law and Justice’s scrutiny and subsequent incorporation of many changes, a revised version of the bill was finally ready for being taken to the last stages of being promulgated. However, timing became a problem at this stage. The bill had several covenants, which related to subjects such as health, education, social welfare and drugs etc. which were previously under the Concurrent List and therefore the justification for the National Assembly to legislate in the area. After the 18th Amendment, these subjects now fall exclusively under the provincial purview and therefore there is little justification for the law to be enacted at the federal level, unless it is enacted for the federal territory and that too once the Constitution is looked at closely with regard to how that can come about.
The provinces should now look closely at this framework to adopt elements into their respective legislative frameworks, in particular KP province where work is ongoing. Whist doing so it is important to note that the original version of the Child Rights Bill, which was drafted with civil society’s input was far more comprehensive than the one that finally got the Ministry’s accent. There are some key issues that were evaded, in the revised version, in particular banning child labour. The reference in the Bill was to the “worst forms of labour” in consonance with ILO convention 182. Many of the worst form of child labour have already been declared prohibited by the Employment of Children Act 1991—also a private member’s bill and the only one to-date. If the new law is to bring value to child rights with reference to child labour, then it should ban child labour altogether or present something that is over and above what has already been stipulated. This is a major step and one that will reflect the true aspirational character of the government.
Secondly, provinces need to start thinking about laws pertaining to the criminal justice system. Pakistan has the Juvenile Justice System (JJSO) Ordinance 2000 in place in terms of a normative framework at the Federal level and now corresponding provincial laws need to be enacted. There are issues with the implementation of JJSO in the sense that Juvenile courts which were to be established under its aegis have not been established in any province including KP. Here is another legislation which is calling for the creation of yet another level of courts, Child Protection courts under the new law. One wonders how that will be accomplished given the current resource constraints and competing priorities.
The existing Ordinance must therefore be revisited. Technical inputs should be solicited and other weaknesses of the ordinance, in particular its reliance on institutional entities as a panacea—a child protection commission, child protection institutions and officers—should be reviewed. Our federal and provincial governments see the creation of commissions and institutional entities as an end in themselves. We also need to be mindful that the creation of many ‘commissions’ e.g the National Commission for Child Welfare and ‘courts’ e.g Juvenile Courts in the area of child welfare have not been honoured previously.
What is more important than these norms is to also work on the social political culture towards greater awareness of substantive issues of national interest. Several weeks have passed since the Ordinance was promulgated and almost a month since the official press conference; however what is surprising is that the legislative framework hasn’t attracted any attention at all in terms of a public debate on its stipulations or the lack thereof.
As part of background research for this comment, grey literature search was performed on key search engines using relevant keywords and websites of major newspapers were searched. There were 2 articles on the subject in all on a matter which touches almost every household in the country. There are more than a dozen reputable newspapers, twice that number of active TV channels, some stellar anchors, significant time devoted to current affairs, a national audience which is now primed to discussions on ‘national issues’. However, this very important subject has not been the focus of attention at all. Children comprise 52% of Pakistan’s population. Children are everybody’s business. We must engage in a substantive dialogue to ensure that the welfare of our children is guaranteed by law.
The author is the founding president of the NGO think-tank, Heartfile. sania@heartfile.org
Poverty and pragmatism
Published in The News International on July 24, 2010:
Some of the statements in wake of the recent meeting of Friends of Democratic Pakistan and strategic dialogues aimed at defining areas of priority for the use of incoming bilateral assistance from Untied States have been positive and encouraging, including the bold admission by Secretary of State ìwe have not done a good job of connecting our partnership with concrete improvements in the lives of Pakistanisówith this dialogue we are working to change thatî. However, when such statements are accompanied by others from the Pakistani side, which label these dialogues ìtransformationalî in relation to breaking new grounds in poverty reduction they usher in expectations, which must be analyzed in the right perspective. Within this context, the comment attempts to explore where the country stands with regard to poverty eradication, the extent to which such expectations are justified, the prerequisites for leveraging the potential within development assistance and the impediments that exist in Pakistan in this regard.
Aid must not be viewed as a magic bullet. However, experiences from many countries, especially in the post World-War II setting show that when it is deployed in the appropriate context and is strategically harnessed it can be a catalyst for change and can help build productive assets and strengthen institutions with a sustainable knock-on effect on poverty eradication. There are many factors which stand in the way of enabling that in Pakistan. This package cannot be regarded a Marshall Plan for reasons argued in these columns on April 29, 2009. These constraints must bring to bear to temper our expectations vis-‡-vis the impact on poverty. Four points are being outlined in this regard.
First, it must be appreciated that several conditions play a significant role in reducing poverty and improving development outcomes. Of these sustained growth, with resulting increase in employment, per-capita income and physical, human, and technological capital are the most important. Sound, consistent and effective policies, good governance, and an environment where peace, security, law and order and justice attract investments are critical for enabling such a transformation. In such an environment sizable poverty reduction becomes achievable when a redistributive hand of the government ensures economic opportunities for the pooróland rights and access to financial servicesóand where impartial oversight attempts to counter organized vested interests and disparities of power, money and resources, to a certain extent. Good governance is the critical enabling factor in this entire equation. Pakistanís constraints with regard to internal security, law and order and governance place it in a position of disadvantage. The latter also undermine the potential impact of traditional targeted interventionsósubsidies, income support, safety nets etc.ówhether they are financed with indigenous revenues or external aid. It is no wondering therefore, that more than a quarter of Pakistanís population is below the poverty line of $1 day, current controversy over poverty empirics notwithstanding.
Secondly, in addition to being critical for national development, the quality of governance also determines the extent to which aid can be effective, per se. To put this statement in perspective, the key inference of an important aid effectiveness monitoring survey with generalizable conclusions should be brought to bear. Two rounds of surveys (in 2006 and 2008) were conducted by the Organization for Economic Cooperation and Development (OECD), to measure the impact of the Paris Principles on Aid Effectiveness. The two monitoring rounds pertinently pointed out that ìin order to change practices in international aid, there is the need to shape deep seated behaviors; these changes in the process of development and the nature of aid relationship require time focused attention and determined political will. It is not easy to change laws, regulations, practices and mindsetsî. The results drive home the point that when there are underlying systemic constraints, the impact of aid is seriously diluted and that the effectiveness of governance in its own right is an important determinant of aid effectiveness.
Thirdly, lessons from the past should be factored into planning as the purse strings are loosened. It is critical that we donít repeat past mistakes. There have been ëthree decades of surgesí in aid in Pakistan in the 1960s, 1980s and 2001-to-date, each time with a strong correlation between geo-political motivations and the volume of aid channeled. On every occasion development assistance is packaged alongside a more substantial chunk of military assistance. Each time, Pakistan enabled its allies to pursue foreign policy objectives but failed to use aid as a strategic input into the system, when viewed from the development and governance perspective. Productive assets, which could generate resources necessary to pay back loans and capacity to mobilize domestic savings and raise revenue, were not built. Grants were used to repay debts. Systemic governance constraints also remained unaddressed. As a result, Pakistanís debt burden and fiscal deficit increased, which is now having a domino effect in many spheres. From these insights some common sense lessons are evidentóin particular, the risk of integrating development and foreign policy objectives, the cost of inattention to substantive long term investments in productive assets, and the short-sighted approach to the use of development assistance.
This time there appears to be an effort not to repeat past mistakes from both sides. But there is just too wide a gap to bridge and too many systemic hurdles in the way. There are some allocations which can be systems strengthening, as in the area of water and energy, but their impact could be mitigated by institutionalized graft and pilferage. Both sides have expressed an interest in negotiating bilateral investment, through the Friends of Democratic Pakistan channel with public private partnerships as a modality, but sophisticated institutional capacity and consistency in policy direction are needed to make use of these channelsóboth of which are non-existent in the country. The new envelope is trying various funding approaches (support for indigenous civil society, program, project and sector-wide approaches, on-budget support and a new multi-donor trust fund) in an attempt to circumvent existing public finance management bottlenecks, but the latter are far too pervasive with very few in the public sector who are challenging status quo. In any case, Pakistanís fiscal crunch means the on-budget component will be substantial, channeled through the existing system with antecedent opportunities for collusion very much at play. There will be an appalling crowding out effect in social sector allocations, unacceptable by aid effectiveness standards.
Lastly, it should be appreciated that development assistance ëas aidí per se, is a small component of ëexternal assistanceí that has helped countries make quantum leaps in development and poverty eradication. The example in our neighborhood is illustrative. At a time when the superpower is signaling good will, an astute government should negotiate better market access, get favorable terms of trade and debt relief. They should focus on their strategic relationship with friends to widen the definition of public goods in the domain of technological solutions, ease impediments on development posed by Intellectual Property Rights and get fairer deals in relation to human resources migration and their working conditions, as the approach can enable earning foreign remittances.
Pakistan should use its strategic position in ways that can benefit its own people, whilst at the same time play a positive role in a globalized world. We need astute capacity, transparent hands, and an unwavering commitment in order to achieve these goals.
The author is the founding president of the NGO thinktank, Heartfile. sania@heartfile.org
Population denominator
Published in The News International on July 11, 2010:
July 11, World Population Day, holds special significance for Pakistan, the sixth most populous country in the world where the importance of Population as the denominator for planning and development must be clearly appreciated. In a country where food, water, energy, education, healthcare, social welfare, and job opportunities are already scarce for the existing population of 173.5 million, the addition of another 173.5 million over the next 34 years will pose a crippling burden in view of prevailing resource constraints. Population therefore, is a true denominator for development. Additionally, a burgeoning young population with limited economic opportunities and social welfare means fuelling the fire of extremism, given that these ‘bleak youths’ would be the perfect targets for exploitation in extremists’ hands. For Pakistan population is also, therefore, the denominator for internal security.
We tend to place the responsibility for rising population on the population welfare program. That shouldn’t be the case. International experiences show that fertility decline is correlated with the level of socioeconomic development in a society. In other countries where it has been achieved, regulatory measures—as in the case of China’s one child policy—have been at play. The former is not the context in Pakistan and the latter not possible owing to the mistaken notion by the masses that family planning is forbidden by religion. All hopes are therefore pinned on the performance of the country’s population program. This perhaps, is also the reason for the current interest in the National Population Policy 2010, which is in the final stages of review. The policy is important as it will come at a time when many structural changes are taking shape. In essence, therefore, the policy will be indicative of how the state system is adapting. With resources now shifted to the provinces, the 18th Amendment calling for wrapping up the Ministry of Population Welfare (MoPW) after abolishing the concurrent list and IMF’s conditionality stipulating likewise, a policy issued from a federal level in a domain which is normatively and fiscally provincial will have to make very good sense in order for it to be palatable. These points are likely to be raised at the next meeting of the National Commission on Population Welfare (NCPW), the inter-provincial forum where the policy is likely to be discussed prior to Cabinet’s review.
Within this context, this comment outlines three areas, an emphasis on which may enhance the policy’s relevance.
First, the policy should be commensurate with stipulated mandates in the sector; it must garner provincial ownership and clearly outline roles and responsibilities. With population as a sector now completely in the provincial domain, would it be possible to carve out a role to justify MoPW’s existence? The answer to this can be in the affirmative if the MoPW devolves its service delivery responsibilities and focuses on a normative role. The MoPW has an untapped potential to assume a leadership role in the population-development paradigm, which remained overshadowed because service delivery responsibilities had previously crowded out the space for normative functions. A new transformed, albeit lean and competent MoPW could be a good economic investment even in today’s resource-challenged environment given the strategic importance of population control.
A service delivery mandate doesn’t mean provinces shouldn’t pay heed to evidence. An earlier, pre-18th Amendment draft of the policy—the current draft is not in the public domain—had outlined an ambitious plan for increasing infrastructure with targets outlined for increase in the number of Family Welfare Centres and Reproductive Health Centres. Even if this has provincial consent, the strategy needs revisiting for a number of reasons: there is currently a moratorium on new infrastructure in many government polices, with which this clearly conflicts. Additionally, there is no convincing evidence of existing arrangements being efficient, which is why the fundamental premise of ‘state owned and operated infrastructure’ is under question. This is evidenced by reform initiatives mushrooming. A policy should outline evidence-based innovations to improve performance rather than signalling intent to increase numbers.
Secondly, the policy should be clear on one of the burning governance issues in the population/health sectors, relating to the standalone status of respective ministries. Pakistan is one of the two countries in the world—Egypt being the other—where the health and population ministries are separate. Several attempts have been made by the government in the past to merge both the institutional hierarchies. When this didn’t appear feasible, UNFPA coined the term ‘functional integration’ in 1998 which then became the mantra and endpoint in efforts to achieve institutional collaboration. However, reluctance on part of both sides—federal and provincial—has been evident with many directives remaining unimplemented, including directives of the Executive Committee of the National Economic Council, Federal Cabinet and NCPW in 1985, 1991, and 2006 respectively. The rationale for functional integration is strong. Health and population have shared agendas, as also emphasized by the International Conference on Population and Development (ICPD), which aimed at a paradigm shift from family planning being a demographic target to a reproductive health end-point. Current fiscal constraints also create an imperative.
A special supplement of the Journal of the Pakistan Medical Association featured an analysis on this subject last year outlining actions that could be taken to bridge the health-population disconnect (http://www.heartfile.org/pdf/SHPP-JPMA.pdf). It would be an imperative for a new policy to come out loud and clear with the specifics of ‘what’, ‘how’ and ‘when’ to eliminate duplications and maximize synergies. Since changes are also happening simultaneously in the health sector it appears that the sustainable long-term solution to the existing population-health disconnect centers on strengthening capacity of both the Ministries for normative and oversight functions and grouping and benchmarking health and family planning as essential services to be provided through reconstituted service delivery arrangements.
Thirdly, the policy should adequately recognize existing inefficiencies in the population program. MoPW functionaries are well aware of the pervasive collusion in field operations of the population program; as a result, commodities are pilfered, fees are charged for services that are meant to be provided for free and there is deliberate inattention to oversight to compel accountability—state resources are wasted as a result and service delivery is undermined. Changes within the existing payment and incentive systems to remedy these fault lines should be a priority for the new policy.
In a way this links to the critical question in governance—one relating to implementation of policies. There has been no dearth of population ‘policy instruments’ in Pakistan. The work of the Family Planning Association of Pakistan, an NGO, which predated the governments program, was supported officially by the government in the early 1950s. Since the early 1960’s every Five Year Plan has made allocations for the sector regardless of whether ‘population’ was housed under Ministry of Health and Labour (as during the First Four Plans) or the Planning Commission and later when it was a given the status of a ministry in 1990. Additionally, the Population Policy was enunciated in 2002 and the NCPW was created in 2006. Furthermore, all health policies, enunciated to date in 1990, 1997 and 2001 have focused on the population issue to some extent. However one view (utilitarian) on a policy is centred not on what a policy states but on what it delivers and on that score, all the previous policy instruments have performed poorly.
In theory, the Population Policy 2010 has been well articulated especially with respect to the domains, which needed to be covered in a policy document. However, this framework must be more than stated rhetoric. It must empower institutions to ‘do more’ so that the systemic constraints that stand in the way of implementing the policy can be overcome.
The author is the founding president of the NGO think-tank, Heartfile. sania@heartfile.org
The budget’s ‘social footprint’
Published in The News International on July 03, 2010:
There was a misplaced euphoria in some social sector circles last year over the expansionary fiscal policy evidenced in Budget 2009/10 and the increase in allocations for the social sectors indicated therein. However, as months unfolded, budgetary cutbacks became apparent owing to grinding fiscal constraints and the donor pledges upon which initial social sector projections were hinged remained unrealized.
Learning from this example, not many rational analysts were perturbed by the scale of outlay this time round in the 2010/11 budget books, given that it appeared comparatively more realistic. In any case, the impact of a budget on social outcomes is not an exclusive function of aggregate social sector allocations, as broader fiscal drivers and other factors can also play an important role.
For example, this year the government’s attempt to achieve macroeconomic stability as a priority in the budget is important as that is a precondition for generating growth, which can have a positive knock-on effect on employment with a direct bearing on socio-economic outcomes. A concerted attempt aimed at reducing the budget deficit and debt burden can lower interest rates, thereby facilitating access of businesses to finance, with the resulting increase in economic activity generating employment. The important emphatic focus on reforming Public Sector Enterprises (PSE) in the budget speech, if implemented effectively could ease the burden on the national exchequer by rationalizing subsidies, which have crowded out the space for productive investments and redistributive allocations—fiscal space could be freed up as a consequence, which could then be used for social sector programs. The proverbial example of the subsidy to one PSE amounting to more than the entire Public Sector Development Program (PSDP) budget of the federal government outlined in the budget speech helps to put things in perspective. Similarly, with the envisaged VAT tax reform commencing in October 2010, it is projected that the tax base and hence the volume of revenues will increase with the expectation that allocations towards development expenditures would be enhanced.
Whilst all these broader economic measures hold promise, there are many caveats in relation to pinning hopes on them. Beyond achieving macroeconomic outcomes, which by themselves are also not straightforward, the success of these measures in terms of accruing equitable benefits depends on a number of institutional, political and geo-strategic factors independent of fiscal handles—there are just too many unanswered questions within that space.
Would the government be able to restructure/privatize PSEs effectively? That too when every restructuring option would involve tough decisions with job layoffs? Would it be possible for a political government to opt for such decisions when they are resorting to massive public sector job reinstatements in other areas? Would there be a way to counter the culture of collusion in big ticket public procurements in PSEs? Which by the way are the most expedient way of recovering election ‘investments’, albeit at the cost of massive fiscal hemorrhage of public resources.
With provincial governments presenting deficit or balanced budgets (for 2010/011) in the midst of massive transfer of resources from the center under the National Finance Commission Award and with them signaling lack of commitment to mobilize their own resources through the ‘tax-free-budget’ rhetoric, would it actually be possible to curtail fiscal deficit within prescribed limits and ingrain fiscal discipline—critical elements of macroeconomic stability? Would the investment climate vis-à-vis the internal security situation be facilitative for businesses to prosper even if policy changes are able to bring interest rates down? Most importantly is there any hope of the energy crisis relenting? As of now, the domino effect of the latter has had catastrophic consequences at the economic and social levels. Would the government be able to successfully implement VAT as a replacement of GST and get past provincial sensitivities and technical issues with implementing the reform? Even if these bottlenecks are overcome and the base of revenue is broadened, the priority it seems, for the use of these additional revenues would be to balance budget books. There is a risk that people may end up regressively paying for public sector inefficiencies and pervasive rent seeking. There are no guarantees that the additional resources would be made available for social sector services such as health and education or that they would be effectively allocated towards grass roots projects which impact the lives of poor. Then is the question of epochal significance related to the quality of overall governance—with elite capture deeply entrenched over the last six decades, the chances of accruing benefits of any positive macroeconomic change equitably to the masses would be limited in any case.
Secondly, concerns about allocations for the social sectors per se, also remain important in their own right. This time round also there is reliance on Official Development Assistance to fund social sector projects, which can be risky if it is outside the tested and committed traditional bilateral and multilateral channels. There are no guarantees that the additional revenues forthcoming would be provided as budget support or under sector-wide approaches thereby being of help to the government vis-à-vis easing pressure on the PSDP. Concerns have also been raised that scaling down of federal allocations for the social sectors might not be covered up, by the provinces correspondingly increasing allocations on their side. Whist this may be true there is no way of documenting this owing to paucity of data in the public domain.
Most importantly, issues of resource utilization will continue to persist. In today’s resource-challenged environment getting the best value for money through measures aimed at cost control, plugging pilferages in the system, limiting abuse, and maximizing efficiencies should be a priority. It appears that the potential impact of these measures is not being fully appreciated. The federal government tends to view the National Finance Commission Award as a way of passing on the responsibility of utilizing resources transparently to the provinces. Provinces, however, are plagued by the same, if not more severe public finance management constraints as the federal government. Without recourse to needed reform in this area that institutionalizes transparency and efficiency, the full potential of additional resources will not be actualized.
Moreover, there are issues in relation to priority areas towards which allocations have been earmarked, as for example, in the case of the approach through which health coverage is being structured for BISP families, a discussion around which has appeared in these columns on June 19.
Lastly, the impact of polices outside of the budget on social outcomes merit attention. Two of the expenditure heads that are backbreaking for the common man these days are inflation and power tariffs. Both are influenced by polices outside of the budget. Inflation has complex determinants outside of fiscal and monetary factors. As far as power tariffs are concerned, regulatory agencies have been created, so that oil prices and power tariffs can be changed outside the budget framework, all year through as and when the need arises.
In sum, it is accepted that there are indeed some measures for social relief in the budget, especially the income support safety net program and revision of pubic sector remuneration. However their impact could be offset by withdrawal of subsidies, indirect taxation, and impact of policies outside the budget. Governance constraints and institutional factors may also undermine the impact of macroeconomic measures pursued through the budget instrument on the equity objective. Broader macroeconomic and fiscal measures may have potential, but their impact depends on many factors, which are not technocratic but largely political in nature. Only time will tell if the well-intentioned policy pursued through the budget instrument has had any impact on the life of a common man.
The author is the founding president of the NGO think-tank, Heartfile. sania@heartfile.org.
The problem with BISP health insurance
Published in The News International on June 19, 2010:
This comment is a review of the health sector policy announced in the budget speech as part of which a new health insurance scheme will be launched for the poor under the rubric of the federal government’s safety net program.
There are two elements in this policy intent. One relates to protecting the poor and the other centres on the means of enabling that. The standalone rationale for both of them is strong.
In principle, the decision by the government to financially risk-protect the poor against the vicissitudes of health is an admirable step since health problems constitute the most common economic shocks faced by poor households, as evidenced by the Planning Commission data. On the other hand, health insurance is a proven means of achieving financial risk protection. However, it must not be perceived that health insurance is the only way of protecting the poor against the risk of healthcare shocks in Pakistan’s context given that there are other simpler ways of enabling that.
Before I dilate how that can be the case, some conceptual clarifications about the state’s role in health financing are offered. The state is meant to ensure that health is financed through public means; either through ‘revenues’ or by ‘pooling’ financial resources. There are two ways of ensuring the latter: one is through insurance and the other is by creating pools of funds, through which cash transfers are made to fund waivers in hospitals for the poor. The idea central to public means of financing is fundamental to protecting people against having to pay out-of-pocket to access healthcare. Some developed countries, which provide universal health financing coverage predominantly, use revenues to finance healthcare, as in the United Kingdom whereas another group of countries, of which Germany is the prototype, use insurance as a means of pooling.
Pakistan’s health system is modelled on the UK’s National Health Service. The Bhore Commission Report (1946), which served as the basis of institutional planning immediately after Pakistan’s inception and the Beveridge Report, the blue print for the UK’s National Health Service, had common authors and emerged around the same time. Pakistan’s public health system, therefore, has a strong post-colonial imprint with a ‘national health services’ model operating, albeit with several gaps. Revenues finance the public system, which comprises over 15,000 health service facilities. Of course there are many pitfalls, lapses and gaps within this arrangement. Absent and ‘ghost’ health workers, closed basic health units, overcrowded hospitals, poor quality and performance are well-described manifestations of Pakistan’s graft-ridden state health system, where inefficiencies are pervasive. This notwithstanding, its original character which embodied universal coverage principles must be brought to bear if any improvements are to be envisaged through reform measures.
Within this context, it must be appreciated that in this health systems model there is a multi-layered system of social protection already operational. Notional costs are levied at primary healthcare facilities for consultations. In hospitals, some costs at notional but most user’s charges are subsidised. There is a mechanism to waive user’s charges for the poor and a system functioning to label ‘the poor’ so. Essentially a local government certified Zakat certificate entitles the needy to free services that involve a user charge in public hospitals up to a limit of approximately 20,000. Over and above this, high-cost diagnostic and invasive procedures not funded through Zakat are meant to be financed through Bait-ul-Mal.
These instruments do have their share of problems. Narrow coverage, poor targeting, lack of predictability about the size of the envelope, opportunities for patronage and abuse, lack of transparency in the use of resources, and corruption scams are some of these. However, with the right ‘targeting tools’ interfaced with the National Database Registration Authority and appropriate tracking technologies, some of these systemic fault-lines can be cemented. There are hospitals where these instruments are making a positive impact despite existing weaknesses and there is every reason to believe that their effectiveness can be enhanced with remedial measures.
Within this context, if the government’s intent evident in the budget speech is to enhance financial risk protection for poor families, then the most plausible thing to do would be to ensure preferential access of the Benazir Income Support Programme (BISP) target families to exemptions/waivers in the existing social protection programmes. Various identification tools can be used for such families, which can allow them a special status in existing arrangements. The additional cost incurred in treating these patients through Zakat and Bait-ul-Mal can then be off-set by funds, which the government envisages allocating for health under the BISP and which currently, are earmarked for insurance.
If appropriately implemented this strategy will help achieve the objective of “improving access of target families of BISP to health care services” with far greater rigour, and efficiency compared to the health insurance route currently being explored.
In the proposed model, there would be no need to get into complex institutional reorganisation from the governance standpoint, which is needed to support the shift in health financing implicit in the new model being envisaged. The risk of alienating the departments of health would be minimised since strengthening the existing arrangements would also be in their interest. The potential of garnering their support as a result thereof would be high. Thorny considerations of commercial viability vis-à-vis returns on public investments would also become irrelevant.
Most importantly, the proposed model would not restrict ‘covered’ healthcare costs to Rs25,000, which is what the insurance ceiling will allow for a family per annum. Instead, it will allow financial risk protection against catastrophic health expenditures, which involve much higher healthcare costs. In fact, this in essence, should be the objective of any health-related social protection programme. Furthermore, the strategy could have a positive knock-on systems-wide effect given that this would also be an opportunity to address some of the systemic avenues for exploitation, which exist within current channels.
The argument in favour of health insurance for this population in terms of its potential to draw on the private sector to deliver state-financed services is also somewhat out of line. On that score, population-based data from Pakistan Social and Living Standard Measurement Survey is telling in relation to the predominant role of public hospitals for the category of services being considered. This further substantiates the need to strengthen social protection financing.
Here it is acknowledged that levering the outreach of the private sector for delivering essential services is a critically needed reform measure. But there are significant legislative and institutional implications, for which the ground is not prepared yet. It is also acknowledged that health insurance, per se, is an important health financing strategy with its own applications even in Pakistan’s health system, where revenue is the main public means of financing health and that there are ways in which the base of social, private and community health insurance and Takaful can be broadened.
In sum, the standalone rationale and merit of the reform measures is not being questioned. It is a question of achieving clarity in the policy objective and structuring the most appropriate means of achieving that. If the priority is to financially risk-protect the poor for health and to do it in the most cost effective and straightforward manner, then the government must rethink its current technical approach. The discouraging response of insurance companies to the expression of interest for the programme, admitted by the BISP managers, is also evidence of the need to do so.
The writer is the author of a recently published book on health reform, Choked Pipes. Email: sania@heartfile.org
Politics of health reform – Part 3
Published in The News International on June 07, 2010:
Pakistan is faced with many unprecedented challenges. Ongoing acts of terrorism, the executive-judiciary confrontation, threats of environmental disasters looming with the Hunza lake bursting at its seams and a storm whipping up in the Arabian sea, a relentless energy crisis, a tough balancing act in the forthcoming 2010-11 fiscal policy, and many others.
With many pressing governance concerns at hand, health reform may appear low on the list of priorities. That notion is misplaced for three reasons. Firstly, health reform is usually an elective process or a course, which is adopted by choice. However, at times it is inadvertently forced on the system because of certain institutional changes that are made outside of it. Such changes in the functioning of the state have already been made in Pakistan and have altered the equation of responsibility in favor of the provinces vis-à-vis the federal government as far as health is concerned. The 18th Amendment to the constitution, the 2010 National Finance Commission (NFC) Award, ongoing reorganization of the devolution initiative are not just political-point-scoring decisions, they have a deep bearing on the executive’s functioning and the manner in which governance has to be reorganized in response to changes in structural norms. The 18th Amendment abolished the Concurrent List under which health was a subject in the purview of both the provinces as well as the federal government. The Local Government Ordinance 2001 stands omitted from the Sixth Schedule of the Constitution and therefore provinces have the prerogative to restructure the local government system according to the mandate in Article 140-A. Under the 2010 NFC Award provinces also have additional fiscal resources to support plans. These institutional changes can be an entry point into health reform with respect to reorganizing the stewardship capacity of state agencies—Ministry of Health and departments of health—which is an important element of any reform measure.
Secondly, the federal government’s budget 2010-11 is just around the corner. This time round under a new fiscal model—the Medium Term Budgetary Framework—indicative ceilings have been stipulated for ministries for a three year period. This is a time window during which handling of responsibilities from the federal to the provincial government as outlined by the 18th Amendment have to be completed. Since the budget is one of the key instruments through which fiscal allocations can signal the directions of change, clear directions must be agreed upon.
The third imperative for health reform stems from poor health status of the country’s population and the need for measures that aim to improve returns on health spending by seeking to address constraints imposed by poorly functioning public systems. Understanding these challenges and the means of their mitigation assume great importance in Pakistan at a time when the need to deliver welfare to the people of the country has never been more dire, given the country’s prevailing geopolitical challenges.
Heath reform is not a short-term measure. Sustained political will, consistency of policy direction and the resolve and capacity to cascade multidimensional changes in a sequenced manner as tangible action into coordinated policies, laws, and institutional arrangements is a prerequisite for its implementation. There are many political and technical capacity constraints, which stand in the way of achieving this in today’s systems of governance. That notwithstanding, the institutional changes, which have been forced on the health system should be used to reorganize stewardship capacity of state agencies. This would, in any case be a prerequisite to implement the reform process if and when the country’s technical and political capacity constraints are overcome.
The opportunity should also be seen in the context of other opportunities in the country that can be capitalized for improvements at the health systems level. Of particular note in this connection is the space that exists to exercise leverage on the potential within public-private engagement to make pluralism in service delivery work for equity and quality. The promising prospects of harnessing the potential within the country’s telecommunication boom to mainstream technology in health systems for gains at several levels, is another. While yet another is Pakistan’s extensive public sector institutional infrastructure, which can be reformed with regulatory interventions and payment and incentive systems. Stewardship agencies need to be reconfigured to reap these low-hanging fruits as a priority. There are changes needed to reconfigure stewardship capacity at all three levels—federal, provincial and district—in order to do that.
At the federal level, the Ministry of Health has an important role even after measures, which have granted provinces more health-related autonomy. However, its core mandate after the 18th Amendment appears to center around normative tasks, coordination, resource mobilization, information and evidence, disease security, ensuring compliance with international health regulations, and streamlining trade in health and the aid effectiveness agenda. Many changes are required in its culture to align its functioning with this mandate. Currently the ministry is swamped by management of a few tertiary care hospitals and manning operational controls of the national public health programs. Its functionaries are overwhelmed by administrative tasks, and managing its subordinate, attached, and allied or ‘autonomous’ departments. As a result the space for normative and strategic work has been crowded out. Much of the time of its functionaries is spent in, which can function better with devolved controls, albeit with appropriate oversight. Its planning infrastructure is weak and there is no institutional entity responsible for human resource planning; the potential of its functionaries remains largely un-harnessed. The ministry’s capacity is also limited to ensure compliance with international health regulations and serve one of its core roles, which relates to the information-evidence-policy cycle. It is performing a mix of normative, regulatory and implementation tasks often with lack of needed separation. A revamped ministry needs to concentrate on its core mandate and develop its capacity in these areas. In the pre-18th Amendment and NFC 2010 era the ministry embarked upon the process of formulating a new national health policy with an operational flavor, which must now be revisited and its orientation changed to one that resonates with the new mandate of the ministry.
Provincial agencies—the departments of health—require a different set of competencies. They have to develop the capacity to plan, implement and oversee a reform process that expands the focus of primary healthcare both with reference to the set of services to be delivered as well as the first point of contact with individuals. In order to achieve this they need to develop capacity to regulate service provision by non-state actors to whom services have been contracted out under programs launched in the last decade and develop protocols for intra-organizational contracting of services from one level of the government (provincial) to another (the district).
At the third tier of government, the need for operational clarity vis-à-vis divisional and district roles is urgent since tussles at this level are undermining service delivery. Districts additionally have to develop capacity to integrate national public health programs with district accounting and accountability channels and hone designated roles for management, quality assurance, evaluation and inter-sectoral collaboration.
Health reform can have many entry points—changes in financing, service arrangements, payment and incentive systems, labor market interventions and social protection arrangements. However for each, institutional capacity at the stewardship level is a prerequisite. There is an opportunity today to draw upon the external drivers to reconfigure systems of governance facilitate health reform. A critical opportunity will be lost if we fail to do so.
Concluded
The author has recently published a book on health reform, titled Choked Pipes. http://sanianishtar.info/choked-pipes.html
Politics of health reform – Part 2
Published in The News International on May 29, 2010:
“In order to judge the character of a nation, look no further than its health system.” This yardstick doesn’t project a positive image of Pakistan, with respect to all the three measures of the performance assessment of the health system–equity in health outcomes, fairness in financing and responsiveness of the system.
But even more serious than the poor health status of the country’s population are the wide inequities prevailing across income groups, rural or urban status of living and across genders. A recent analysis by the writer has shown statistically significant differences in health outcomes across quintiles of income measured in the Pakistan Demographic Health Survey database.
Three vertical “health systems” with mutually exclusive service delivery infrastructures, human resource, governance arrangements, and public or publicly-mandated private means of financing exist in their own right. These include health systems of the armed forces, the Fauji Foundation, and the Employees Social Security Institute. Collectively, these cover 14.20 per cent of the country’s population. The predominant health “system” in the country can be described as being “mixed.” Here, out-of-pocket payments and market provision of services predominate as a means of financing and providing services, alongside publicly financed government health delivery.
Two horizontal “health systems” provide health coverage to an additional 2.38 per cent of the population through this mixed system. These are the health systems of quasi-autonomous agencies of the government and the corporate sector. They use insurance or reimbursements as a means of financing but access the public or private sectors for service provision. Revenues fund healthcare for 15.22 million public-sector employees. In addition, 500,000 poor individuals are covered under safety nets. It can therefore be inferred that quality issues notwithstanding, 26.62 per cent of the population of the country is covered for healthcare costs, while 73.38 per cent is not, and makes some level of out-of-pocket payments to access healthcare. Recent health financing analyses show that out of the total amount of GDP spent on health (2.90 per cent), 1.16 per cent is contributed by the public sector whereas 1.73 per cent is contributed by the private sector. Predominance of out-of-pocket payments and private financing–regressive means of financing health–show that Pakistan fares poorly with regard to “fairness in financing,” the second parameter of performance assessment.
A cursory examination of data from the Pakistan Social and Living Standards Measurement Survey of the Federal Bureau of Statistics shows poor performance with reference to the third domain, responsiveness. More than 70 per cent of service provision in health is by the private sector, but the state doesn’t harness its capacity to deliver health-related public goods.
The poor performance of Pakistan’s health system is in stark contrast with what Pakistan has stated in its successive policy frameworks and planning instruments. The design of Pakistan’s three-tiered public infrastructure, a response to the international Alma Ata Declaration, has encouraged the mistaken notion that the state is pursing the goal of Health for All. The nature and magnitude of fundamental distortions in Pakistan’s health system, therefore, make health reforms a strategic imperative.
A number of systemic changes are needed in the mechanisms of financing, delivering and governing healthcare, and in the means of providing inputs into the system (human resource, medicines and products), in order to meet the objective of Health for All. Healthcare is strongly influenced by the broader systems constraints within the sphere of political economy: without debt limitation, fiscal responsibility and measures to broaden the tax base, there won’t be fiscal space available to allocate monies to the health sector.
There can be many entry points into health reform; change in financing arrangements is one of them. The objective should be to move towards public sources of financing (revenues and/or pooling) as opposed to private means of financing predominant in Pakistan. Here, Pakistan has to incrementally make indigenously relevant changes. Gradual increase in revenues is important, but more important is the reorganisation of existing financing. This can be achieved through action outside of the health sector and legislation to make it binding on employers to pool for employees through payroll taxes or employers’ contributions for the formally employed sector. For those in the informally employed sector, there are options to broaden the base of social protection by augmenting existing waiver and cash transfer systems. Reform of the state’s current arrangements (Zakat and Bait-ul-Mal) is critical in this space.
Management re-engineering of public-service delivery can be another entry point into health reform. It is envisaged that, with adequate re-sourcing and management re-engineering on private-sector management principles, workforce can be retained in the public sector, availability of medicines, supplies and infrastructure can be improved, and public facilities can be better managed. Similarly, market harnessing regulatory approaches to broaden the first point of contact in primary health care can be another entry point of health reform in Pakistan’s setting. This approach can also enable purchase of services in order to achieve equitable access to care.
In most reform plans, institutional reform of state agencies mandated in a health role is needed to varying extents in order to enhance their normative and oversight capacity to implement and sustain reform. Institutional separation of policy-making, implementation and regulatory functions is usually a feature of such reorganisation. Most reform plans need to be supplemented with other changes, as has been observed in the case of the recent US health reform plan. Notable amongst these are the use of technology in order to assist with securing the distribution chain, making procurements transparent, optimising time and connectivity in health information systems, and bridging gaps in training, continuing education, and information dissemination
One must also not lose sight of the context in which support for implementation of health reforms has to be mobilised. With the budget sessions starting, experts are arguing for the need to curtail fiscal deficit as a priority and cautioning against an expansionary fiscal policy. Such a course will have fiscal implications for the social sectors. However, it is precisely in such a fiscally-constrained environment that the question of improving returns on spending needs to be prioritised in order to address constraints imposed by poorly-functioning public systems.
In this context, a recently released plan offers a roadmap to the reform of Pakistan’s health sector in a phased manner. In addition to synchronised changes at the policy, legislative and institutional level, the plan draws attention to a number of structural factors within and outside the healthcare system, and lays emphasis on reform of governance and social welfare as an important adjunct to reform within the healthcare system. The reform roadmap is relevant to current efforts aimed at achieving development goals in today’s macro-economically constrained environment and meeting broader development objectives in the context of Pakistan’s geo-strategic challenges.
(To be continued…)
The writer is the author of a recently published book on health reform, Choked Pipes. Email: sania@heartfile.org
Viewpoint 78: Politics of health reform – Part 1
Published in The News International on May 22, 2010:
Ever since the enactment of major health reforms in the United States, global interest in the subject has burgeoned. For Pakistan, health reform should be an imperative for reasons that have been glaringly apparent. Cases of alleged malpractice by the private sector have soared to new heights over the last several months. There are various versions of healthcare ‘bills’ circulating as structural solutions to this deep-rooted problem, albeit with limited technical potential to impact change and almost no stakeholder buy-in. The menace of spurious drugs and procurement graft relating to medicines has been commanding attention of the superior judiciary. Dilapidation of primary healthcare has been a prime subject of media attention and the Pakistan Medical and Dental Council’s scuffle continues to smoulder.
Although these issues appear to be standalone problems, they are, in effect, deeply interlinked and are cogs in a convoluted chain, which a consolidated attempt at holistic health reform has a high likelihood of unravelling and streamlining.
Two things must be understood about the dynamics of health reform. One, that it has to be an indigenous process. And two, that it is a profoundly political process.
With reference to the former, health system’s issues are closely inter-linked with a country’s body politic — so are the solutions. The strategies to be employed in the context of a nation state to remedy its health system’s woes are unique to a setting, and whilst lessons from similar countries have relevance, there isn’t a perfect fit. Health reform, therefore, means very different things in different contexts.
In the United States, for example, where a publicly-funded system exists alongside a more predominant market system of pooling and provision, reform proposals in the past have centred on many strategies: removal of the private insurance market and establishment of a public option, premium subsidies to help individuals purchase health insurance, medical liability reform, policy options to reduce healthcare costs, etc. Through the recently enacted law under which insurance coverage is being expanded, the country is moving towards addressing the nation’s fundamental health sector anomaly — the US is the only industrialised democracy which didn’t until now provide universal coverage or financial risk protection to its population, and hence the medical bankruptcies.
Other developed countries that do provide universal coverage, adopt hybrid arrangements vis-à-vis service provision and health financing. In Britain, Spain and Italy, revenues fund healthcare and service provision is largely in the public domain. In Germany, France, Netherlands and Switzerland, the means of financing is predominantly pooling or insurance but service provision is by private doctors whose potential has been harnessed by the state to achieve universal coverage goals. In other countries such as Canada, Taiwan and Australia, there are blended systems with private sector doctors and hospitals but with public insurance. The reform connotation in each of these settings is unique and is interlinked with the body politic and overall prevailing systems of governance in the nation state. In these countries, elements of competition, supplier/buyer roles, patient choice, diversity of providers, freedom for hospitals, stronger commissioning, new payment mechanisms, modalities of fund management, quality, measures for compulsory participation, government subsidies to cover the poor, and price regulation, etc., have strongly featured as pathways for health reform, over the years.
The contemporary understanding of health reform in the developing countries has been shaped by reforms introduced by international agencies in the 1990s and have been linked to the concept of neo-liberal reform. These attempts at health reform used a variety of entry points with organisational efficiency as an outcome — introducing insurance, changes in payment systems, decentralisation, alternative modes of primary healthcare delivery, and hospital restructuring are examples of reform initiatives pursued by various countries in the past. Most reform attempts sought to improve the efficiency and quality of primary healthcare by structuring the role of the market in healthcare provision with separation of purchaser and provider functions as a major institutional overhaul. While some of these reform efforts positively impacted access, quality, and efficiency, they also came under criticism due to their perceived ideological conflict with the principles of Health for All. It is critical that in addition to efficiency gain, developing country health reform should also be configured to impact outcomes, with fairness in financing, enhanced responsiveness, and reducing barriers to access as endpoints.
Lessons from around the world in health reform have important insights for reforming Pakistan’s health system. The latter can be described as ‘mixed’ where public provision funded by revenues co-exits with a market system of service delivery, with people accessing care through out-of-pocket expenditures. There are specific options to reform such systems by incrementally increasing and reorganising health financing, harnessing the role of the market to achieve universal coverage goals and reorienting stewardship and regulatory capacity to support that objective. Such changes are transformational but are critically needed to address the unacceptable level of preventable deaths and disease that plague people of this country.
In order to understand what stands in the way of making the needed transformational changes in Pakistan’s health sector, we need to examine the second fundamental point about the nature of health reform in terms of its dynamics being highly political.
In countries with a strong societal political culture and where healthcare accounts for one of the largest areas of spending, health reform is surrounded by hotly-contested political debates. This was evidenced by the difference in opinion between the Conservative and the Labour Party over the introduction of the purchaser-provider split in Britain some decades ago, and more recently, has been illustrated by the divergence of views on the type of fixes supported by the Democrats and the Republicans in the US in the last election, with the former leaning towards broadening the base of insurance and the latter supporting open market competition in order to cut costs.
In Pakistan, with the social political culture being weak, there are no ‘pressing’ public demands for healthcare. The constitution does not explicitly recognise the right to health, although there have been progressive case law interpretations of the ‘right to life’ as also being inclusive of health rights. These judgments haven’t, however, had a knock-on effect with citizens going to courts and demanding that their right to treatment be enforced as has happened in many countries of South America where the right to health is constitutionally recognised.
In Pakistan, the most damaging aspect with regard to the politics of health reform has been the lack of policy consistency. There have been many programmes initialised since the creation of the country, which had the potential to lead to transformational change, if they were sustained and if evidence was used to upscale them. In contrast, a plethora of restructuring pilots was never evaluated, and those who decided on their fate prioritised planning based on what was politically expedient. There is a long list of lost opportunities where public monies were wasted in pilot projects that couldn’t be institutionalised and the opportunity to save millions of people from death, suffering and disability was lost.
Reform in the social sectors and in many spheres of governance is a long haul. It cannot come to fruition with the governments changing policy positions ever so often, when they are vying for quick visible outputs in the run up to the next election, when administrative agencies have limited technical capacity and when there is no accountability of politically expedient decisions.
Pakistan must place health reform as a priority on its public policy agenda and tailor it to the local context with respect to economic realties, political circumstances and administrative capacities of local institutions. There are too many people dying as a result of lack of attention thereof.
To be continued…
The writer is the author of a recently published book on health reform, Choked Pipes. Email: sania@heartfile.org
The penchant for provinces
Published in The News International on May 08, 2010:
Calls to create more provinces in Pakistan have intensified ever since NWFP was renamed Khyber-Pakhtunkhwa. People of district Hazara are out on the streets with their demand for Hazara province. A motion was moved in the Senate during the 18th Amendment session with the suggestion that district Bahawalpur be given a provincial status and pictures of students carrying placards of ëSariaki provinceí have been featured in newspapers ever since.
While the renaming of NWFP is symbolic and recent attention to this subject motivated by ethno-lingual fervor, it is important to pay heed to these calls in view of Pakistanís past, vis-‡-vis the events of 1971 and recent notions mooted by Baloch separatists. This comment is an attempt to draw attention to three questions in this regard.
The first question relates to the fundamental validity and justification for such calls. Contrary to popular belief, the demand for more provinces is not necessarily analogous to an anti-state and/or separatistsí connivance. In fact, increasing the number of sub-national governmentsóin other words provincesócan strengthen a multilingual, multiethnic federation and can be a useful way of garnering support and ensuring that federating factions have a vested in strengthening the federation. Allowing people to own their identity makes them feel part of the mainstream, less dominated and therefore, not alienated. These attributes are vital to the viability of a federating system.
Observations from many other developing countries and economies in transitionódifferences in geographic and population characteristics notwithstandingóalso provide a justification for increasing the number of provinces. It has frequency been cited that many countries in our immediate neighborhood and others with comparable population size have a far greater number of provinces. All of these countries are thriving federations, which goes to show that the number of sub-national governments does not appear to undermine the viability of a federating system.
Furthermore, Pakistan has an additional structural justification for revisiting and increasing the number of its provinces. One of its provinces is larger than the sum of all the others combined in terms of population sizeóPunjab represents 58% of the total population of the country. There are difficulties inherent to the functioning of a federation when that is the case. This is evident in the relationship of Punjab vis-‡-vis the federal government and other provinces at the political and economic level, the details of which, the word count limit on this comment does not permit me to delve into.
Whilst dilating upon the justification, it must also be brought to bear that while the subject appears to be under the lens subsequent to renaming NWFP, this is by no means the first instance. Many recommendations and notions to this effect have been mooted previously. An unpublished viewpoint has called for the subdivision of each province into three parts, resulting in the creation of 12 provinces. Another publication in the public domain has made a case for adding more provinces on ethno-lingual basis, alluding to the possibility that Khowar, Kalasha, Kohistani, Seriaiki, Potohari, etc. provinces can be created. Other less pragmatic ideas have also been flagged recommending that each district be granted a provincial status. Moreover, the creation of Gilgit-Baltistan province, though in a different context than the one under discussion, is nevertheless an indication that such drastic changes in the architecture of sub-national government are now acceptable.
The second question: Will the creation of more provinces, per se, improve state governance and ensure that state mandated servicesólaw and order, justice, health, educationóare better served? The answer to this is clearly, no. Breaking the country into more provinces is not an end in itself. It can however, be a means to a desirable outcome if creating more provinces is coupled with the grant of meaningful provincial autonomy in ways that incentivize performance enhancement and institutionalize overall checks and balances. This can have a knock-on effect on sub-national governance with benefits accruing to populations beyond the process outcome of redrawing provincial boundaries.
The third question relates to the feasibility and appropriateness of opening up this Pandora box in the country at this point in time in view of the current circumstances. The timing is, unfortunately, not as well placed to make structural changes as is their justification. There are too many things currently in the pipeline, which can impact provincial governanceóthings that havenít yet come to fruition. Provinces are half way in getting some control over their resources through the National Finance Commission Award the 18th Amendment stipulation with regard to the abolition of the Concurrent List has created a set of imperatives for transferring authority with a range of transformations in relation to a number of subjects previously under the Concurrent List. This has political, administrative and fiscal implications. An additional complexity relates to lack of clarity about the local government system, which impacts many attributes of local governance, from its working to the development of grass roots democracy, the functioning of judicial magistracy and citizenís empowerment.
With provincial mandates in a flux and the local government system undergoing a transition, opening another major chapter by calling for more provinces will add another level of complexity and doesnít appear prudent whist the state is grappling with many internal security and macroeconomic challenges.
It must also be recognized that creating more provinces will have major fiscal implications. With the balance sheet in a perpetual dire strait, and the country in the International Monetary Fund fold, plans for resource-intensive elective state restructuring are unlikely to have appeal for the factions that hold the purse strings. There are many competing priorities for investments, for example energy and targets set for cutting down establishment costs, which are additional reasons why support for this idea might not meet approval.
Even if that barrier is overcome, capacity constraints will have to be addressed. Federating units have to have the capacity and infrastructure to mobilize revenues, manage their own natural resources and trade in a very complex global environment in order to be effectively autonomous. Recent experiences with negotiating the NFC award demonstrate weakness in the ability of existing provinces in many of these aspectsócarving out more provinces will entail the development of these capacities from scratch, which would be an extremely complicated task.
It may be feasible to use the one-year transition period stipulated under the 18th Amendment with regard to transfer of responsibilities to the provinces to develop a model of effective provincial and district functioning before putting the idea of ëmore sub-national unitsí on the table. This process will require careful consensus-building at the national level. The time can also be used to think through the implications of more provinces on issues such as provincial representation in the Senate.
In sum, therefore, increasing the number of provinces can be justifiable on many grounds. The approach can also be in synergy with ongoing efforts to grant provinces more autonomy. However, there are major constraints in embarking upon this highly charged political process with the country engaged on so many fronts and whilst evidence of the effectiveness of recent inanities to grant provinces more autonomy is not available to inform the next steps.
The implications of whipping up ethno-lingual zeal in support of more sub-national units and the chain reaction that it can lead to must be clearly thought through. What is important is to be clear about the underlying motive. The latter should be to improve governance and improve service delivery and not to carve out agendas for political forces that operate on the periphery.
The author is the founder and president of the NGO Thinktank, Heartfile. sania@heartfile.org
Parliamentary Empirics
Published in The News International on April 24, 2010:
The 18th Amendment to the Constitution is being hailed on a two-fold premise: one, that it will proclaim and empower the Parliament as supreme; and two, that it will fundamentally redress the basic anomaly of Pakistan’s parliamentary system of government, which has been presidential in substance after the 17th Amendment and, therefore, configure its true parliamentary form.
It is acknowledged that the Amendment has rectified a fundamental distortion in the Constitution. Its importance notwithstanding, the Amendment does have its limitations in upholding parliamentary supremacy in a context where distortions are pervasive. A snapshot of available empirical details about parliamentary performance can be insightful in this regard.
Pakistan’s bicameral federal legislature comprises the president, the National Assembly and the Senate. The National Assembly has technically been fulfilling the constitutional requirement of holding sessions for a certain number of days per year for sometime now. However, as the key institution of democracy, it has not performed optimally in relation to some of its key functions, particularly with regard to holding the government accountable for actions, scrutinizing its performance, monitoring the expenditure of public funds, and providing an effective forum for deliberations on matters of national interest and for addressing substantive grievances.
The assemblies have had almost no role in deliberating upon, scrutinizing, and therefore holding the government and its policymakers responsible for decisions in some key public policy domains and the impact as a result thereof. Foreign policy and substantive economic issues are seldom the subject of debate in the assemblies. Fiscal policy is discussed as part of the budget deliberations, where a complex package of policy decisions are bundled in a single cumbersome instrument which is conventionally scurried through the process in an unnecessarily tight timeline. The recent change in the budget time cycle is positive but given the limited analytical ability of parliamentarians, lack of indigenous research and technical capability and disconnect from policy agencies outside the state sector, it is unlikely to transform the process outright. In any case, the frameworks that determine fiscal directions and planning at an overarching level—Poverty Reduction Strategy Paper, Medium Term Development Framework, the International Monetary Fund frameworks and agreements, and stipulations of bilateral and multilateral agency grants and loans—are never placed in the parliamentary domain for discussion, nor are their implications highlighted in layman’s terms for public representatives to comprehend. These have a huge immediate and long-term impact, both within and outside of the fiscal rubric, but are never the subject of public scrutiny.
Similarly, whilst it is acknowledged that policymaking is the government’s mandate, there is a lot of value to be added when policy positions are deliberated upon in the Parliament. This becomes all the more important when the executive is drawn from the legislature, and also since laws can be instruments of policy in their own right. However, that is seldom the case and formal policies are usually channeled from the executive to the Cabinet for approval, bypassing the assemblies.
The parliamentary committees, where the Parliament is meant to be ‘at work,’ have limited capacity and no substantive research fall back. Hence, one of the potential strengths of the Parliament, which has to do with providing a platform for deliberations, oversight, and scrutiny, is not being appropriately harnessed in Pakistan’s parliamentary system. As a result, the executive remains largely unchecked in its decision making prerogatives.
These anecdotal insights and observations have been substantiated by evidence from a recent study conducted by the Pakistan Institute of Legislative Development and Transparency (PILDAT). The evaluation of the Parliament in Pakistan was based on an analytical framework developed by the International Parliamentary Union, the international apex body of parliaments of sovereign states and was centered on six domains. In the ‘representativeness’ domain, the study results show that the weakest aspect of representation of the National Assembly is the near impossibility of a person of average means to get elected to the Parliament. In the ‘effectiveness’ stream, the weakest aspect of parliamentary oversight over the executive is reported to be related to its inability to scrutinize executive appointments. With reference to the ‘effectiveness of legislation,’ the capacity of the National Assembly and weak processes for consulting various interest groups are highlighted as the main constrains. The weakest aspect of ‘transparency’ is related to lack of opportunities for citizens’ involvement in legislation through citizen-based initiatives. In the domain of ‘accountability,’ gaps in transparency of procedures to prevent conflict of interest in the conduct of parliamentary business and limited oversight of funding to candidates and political parties have been flagged as issues. In terms of ‘effectiveness of the National Assembly’s involvement in international policy’, the following constraints have been highlighted: limitations of the Parliament to scrutinize and contribute to the government’s foreign policy; lack of availably of information to the Parliament on ongoing negotiations with international entities; and inability of the Parliament to influence the government’s development policy as a donor and recipient, and international relations in general. However, the report also acknowledges some plus-points with reference to representation of women in the Parliament and freedom to journalists in reporting on the National Assembly and its members.
Despite many constraints, some recent improvements in parliamentary performance must be acknowledged. These include the Prime Minister’s respect for parliamentary etiquette, appointment of the leader of opposition as chair of the Public Accounts Committee and increase in the time-cycle of the budgetary debate, as already mentioned. Similarly, the Acts to Ordinance Ratio has been improving. In the 12th National Assembly, the Acts to Ordinance Ratio was 42:73. In the first year of the 13th National Assembly, the ratio remained likewise, 4:17, but an improvement has been evident in the second year with an Acts to Ordinance Ratio of 29:27. The recent constitutional amendments impose a limit on the number of times an Ordinance can be renewed and hence there will be safeguards against a pattern that was established earlier—three Ordinances were re-promulgated 10 times during the tenure of the 12th National Assembly.
Whilst these changes are welcome, we must be realistic about our expectations in view of what has been stated previously. The reform process, which has begun with constitutional amendments, has a very long way to go. It is imperative that we mitigate the influence of feudal and business interests in the Parliament, counter the role of big money in politics, and prevent conflict of financial or other interests. This is a huge Pandora box in its own right as it has to do with reform of the political process itself. The unfinished business of 17(4) and 63(A) does not inspire confidence in this respect. It also requires a transformation in the capacity of the Parliament and its institutional culture with reference to transparency, openness, disclosure and harnessing the capacity of the non-state sector.
It must be recognized that the problems in the Parliament are not amenable to technocratic fixes but are related to some deep-seated problems in the manner in which the executive operates in relation to legislature, particularly with reference to the latter’s scrutiny-related function. Many loopholes exist to bypass processes and protocols, as and when the need arises. With the President as head of the ruling party, the avenue to wield influence over the executive remains open even after the 18th Amendment. Only time will tell if that power is exploited or not. Meanwhile, we have to be cautious about our expectations of the Parliament in a very complex space.
The author is the founder and president of the NGO think-tank, Heartfile. sania@heartfile.org
Sanitising the constitution
Published in The News International on April 09, 2010:
The 18th Amendment Bill is being widely hailed for repealing some of the distortions introduced in the Constitution in previous years under military rule and for returning the parliamentary form of democracy closer to its truer shade in Pakistan. A multi-partisan consultative process has enabled a consensus over a set of provisions amongst political actors, who came to the negotiating table with diverse ideologies and motivations. Commendations are, therefore, due to the team that led the process. However, there are many caveats in relation to the way forward. Significant as it may be, the amendment is not a panacea for the country’s ailing governance. It is critical that the quantum of changes in the structure of the state envisaged through the amendment and the imperatives that these create for follow-up actions needed for transforming the style of governance, are appreciated. I have attempted to flag six points in this regard.
First, with the 18th Amendment, the pendulum of power will move from the presidency towards the prime minister, as it should indeed be the case in a parliamentary system of government. However, it would be critical to ensure that there are institutional checks on the prime minister’s powers. As ‘fusion of powers’ is characteristic of parliamentary systems—in the sense that the executive, which consists of the prime minister and the cabinet, are drawn from the legislature—the need for institutional checks and balances becomes all the more important. We must also recall the generic weaknesses of the parliamentary form of government and examine if/how they are impacting our parliamentary system. Although the latter is widely recognized as being both responsive and responsible, some internationally recognized weaknesses of the parliamentary form of government should be brought to bear. The parliamentary system runs best in a two party-system. However, when no party commands an absolute majority and when coalitions are formed—as is presently the case in Pakistan—governments are seen fire-fighting most of the time. Lack of the needed far-sighted and consistent stance on many policies is, therefore, not just a limitation of capacity within Pakistan’s system and shortsighted motivations of its policymakers, but also a limitation of its parliamentary system—a weakness the pendulum swing cannot address. There are many dire imperatives for ensuring consistency in policy direction in Pakistan, particularly from a national security standpoint—a point I have attempted to highlight in these columns on April 3. Now that the sword is no longer hanging on the parliament, it should turn its attention to these substantive issues and the constraints implicit in party antagonism and tenuous coalitions. It is imperative to create space for a working relationship within the current political and democratic dispensation that can work in the interest of the state and its people.
Secondly, the government appears to accord high priority to provincial autonomy on its agenda. After pronouncing the Balochistan package, carving Gilgit-Baltistan as a separate province and negotiating the National Finance Commission Award, the 18th Amendment Bill has abolished the Concurrent List and has revitalized the Council of Common Interests. The government uses the jargon ‘participatory federalism’ for its policy stance in this area. There is no denying that provincial autonomy can be the foundation of a strong federation and the government’s policy, in principle, is the correct stance. However, attention should be paid to reservations being mooted with regard to the implications of this for governance at the provincial level, in view of their limited capacity, at least in two of the provinces. The cost of making drastic changes in the functioning of the state without appropriate analysis and evidence has already been evidenced in the devolution debacle. Drastic changes in federal-provincial relationships can be exploited by non-bona fide entities in today’s environment with an adverse fall-out on the functioning of provincial administrations at a time when terror, ethnic strife and ideological differences have been whipped-up to unprecedented levels. In some provinces, the risk related to blurring of the difference between autonomy and mutiny cannot be ignored anymore. The impact of waning federal oversight on collusive behaviors in the provinces also merits careful analysis. The government must, therefore, develop a phased, incremental and prudent approach towards provincial autonomy.
Additionally, abolition of the Concurrent List in toto will limit opportunities for legislation of a normative nature—particularly norms which relate to the fundamental ethos of the Federation. Similarly, domestic legislation as a follow-up to international commitments need not be a provincial prerogative, where capacity constraints can cause delays and duplications would be inevitable. The Charter of Child Rights bill—currently in the pipeline—illustrates both the cases. The ten year-overdue domestic legislation as a follow-up to the United Nations Convention on the Rights of the Child is both normative in nature and in compliance with an international norm; it can be federally enacted and have the same meaning for each of the provinces.
In the third place, the 18th Amendment Bill attempts to address some of the processes that have the potential to make governance ‘participatory’ and ‘efficient’. The former is evident in the stipulated procedures for appointment of superior court judges and the chief election commissioner and the latter in the provisions, which limit the size of the cabinet and the number of advisors. Whilst these changes are welcome, there are many other things that need to be initialized as a follow-up to improve governance. The civil service reform agenda awaits implementation. The accountability law, the pulse of good governance, is on the backburner; the competition commission law is on hold; the National Anticorruption Strategy has remained shelved; opportunities to use e-governance to promote transparency in governance remain untapped; conflict of interest within the policymaking ranks continues to be pervasive and administrative norms within the bureaucracy have been unchanged. Holistic reform in these areas should now be the next step.
Fourthly, the bill introduces free and compulsory education up to the age of 16 years. This is a significant step towards recognizing the right of a child to education. But this stance has implications for resource allocations and institutional frameworks. The government currently does not have the structures to enable that. With education predominantly in the hands of the private sector, a quantum shift is needed on the policy stance towards ‘purchasing services’ from the private sector. This has implications in turn for regulatory capacity of the government with resource requirements being a corollary. Admirable as it may be, this commitment will have to be followed up with some serious reorganizing in-house. In the same vein, however, health has not been regarded as a right, which is disappointing and the expectation that the amendment would pay heed to social rights holistically has not been fulfilled.
In the fifth place, with regard to renaming the NWFP, the connotations of the new name vis-à-vis the events surrounding partition of the sub-continent should be brought to bear. It is unfortunate that this move is inadvertently sowing the seeds of discord in the province with calls for the creation of another province echoing loud even before the bill is debated.
Finally, in relation to high treason, the expanded definitions will hopefully block ad hoc adventurism in the future. I wish there could also be constitutional mechanisms to label those that sacrifice vital interests of the state on altars of personal interests as committing high treason as well.
To conclude, the bill is indeed an achievement in terms of having sanitized the constitution; but as far as governance is concerned, there is a long way to go. Lasting solutions demand integrity and unwavering resolve in an environment where the strong tide of political point-scoring and short-sighted public policy orientation will risk rocking the boat at every stage.
The author is the founding president of the NGO think-tank, Heartfile. e-mail: sania@heartfile.org
National Security Policy
Published in The News International on April 03, 2010:
Pakistan’s prevailing situation should lend impetus to strategic thinking about a holistic vision for a National Security Policy. The imperative to do so is two-fold: one, the contemporary understanding of security within the context of a nation state has broadened from one centered on territorial sovereignty and therefore, military and political prowess, to one encompassing a holistic vision. The latter enables addressing both, factors upon which territorial sovereignty is dependent as well as human security—economic security, environmental security, food security, demographic security, and health security assume importance in this respect. Two, because sustainable state security is dependent on human security.
A review of several decades shows that some key solutions, which had the potential of securing sustainable economic security for the country have not been effectively deployed. Ensuring economic security is key to maintaining security systems and ensuring people’s welfare. Pakistan debt burden, dire conditions of its balance sheet and reliance on development assistance to finance vital areas does not inspire confidence in that respect.
The water crisis has remained unresolved and has become a subject of political point scoring; as a result an energy crisis has become deeply entrenched. Pakistan’s 3000 MW shortfall in the context of the estimated 40,000 MW potential is a stark reminder of institutional and political impediments, which have played to the detriment of needed investments in infrastrcture vital for ensuring energy security—the lifeline of econonomic development and a prerequisite for ensuring economic security.
Measures to mobilize revenues by widening the tax net have remained stalled because of vested interests of the elite, which have captured the public policy process. Curtailment of expenditure has also not been possible for the same reason. The balance sheet, therefore, provides very little space and the realization that Pakistan’s fiscal equation can be hit hard by an external factor in a globalized world—such as international oil prices and another financial downturn—is a cause of great concern.
Lack of consistency of policy direction, the internal security environment and pervasive power shortages are leading to under-performing industrial and business sectors and are hurting investments and employment as a consequence. All these considerations do not auger well for ensuring economic security. In addition weaknesses in governance are leading this country with an agrarian economy towards food insecurity.
With virus entrenchment in Asia now well established and past experience with the havoc disease pandemics can cause, health security has become a genuine cause of concern—something the public health system has limited capacity to cope with.
To add to these security concerns are internal security threats. Pakistan’s unique pattern of conflict and ethnic and religious divides have paved the way for unprecedented violence and terrorism. These threats are being compounded by two factors: one economic hardship and two, rapidly growing impoverished populations, vulnerable to exploitation. Both of these are the result of poor governance. The cost of inattention to these is precisely the reason why FATA is such a hotbed of trouble today.
High unemployment rate, inflationary pressures, escalating tariffs and limited opportunities for fall back on welfare services have pushed the poor and even the middle cases to unprecedented levels of economic hardships. People are additionally being drawn to the limits of tolerance with the prevailing commodity shortages, which can be easily prevented and averted with careful economic management. With the eroded capacity of the state to dispense justice at the level of subordinate judiciary people are out on the streets and are taking law enforcement in their own hands. The parading of ‘thieves’ is a proxy indicator of impending anarchy and spells widespread unrest. These circumstances are the perfect breeding ground for ingraining extremist ideologies—a situation the extremist elements in the society are exploiting to the core. With a burgeoning population and failure to ensure demographic security as a result thereof, the quantum of these internal security threats will unfortunately increase over time and will continue to challenge the writ of the state and terrorize and demonize its populace. This situation has not developed overnight. ‘Strategic’ mistakes of several governments are contributory to what prevails today.
One can almost pull a thread through the causes of these manifestations. Although weak governance, limited accountability, pervasive corruption, inefficiencies, lack of democracy in previous years can all be blamed for these trends, there is one determinant, whose relative contribution in the prevailing mayhem is most salient particularly with respect to economic and human security—lack of policy consistency and the absence of an accountability framework to monitor how policies are followed through. Nowhere is this more damaging than in areas, which are of vital security interests of the country.
For developing countries lack of policy continuity can be most damaging. Continuity of policy direction has been the key determinant of the growth, development and prosperity that many countries in Asia now experience, weakness in their democratic credentials notwithstanding.
In Pakistan’s 63 year history, except for certain elements of our foreign policy, there has been no consistency of policy direction particularly with reference to macroeconomic and social sector management. Governments have adopted polices and subsequent governments have disregarded them, have sidestepped, detracted or retracted.
Every incoming government aspires to have its ‘own’ policy on every issue and deems it necessary to re-pronounce or repackage an existing policy regardless of the time implications and without consideration for the value of time, intellectual input or resources lost in changing course. Technical input is often overlooked in the process, feasibilities are set aside, negotiated plans remain unhonored, projects funded with loans to be repaid with tax payer’s money don’t come to fruition in the process. The fixation to show that new polices have been enunciated and the motivation for new contractual agreements are grounded either in gaining shortsighted political mileage or opportunities for markups in new arrangements. In such an environment, strategic decisions are held hostage to political point scoring. With a style of governance characterized by ministers focused on these objectives and with technical capacity of ministries eroded, majority of bureaucrats politicized and credible ones sidelined or disempowered there are very few custodians of state interest in the decision making hierarchy who want the pendulum of decision making to swing in favor of national security interest, defined in holistic terms.
It is within the context of this vacillating stance on policies and politically expedient decisions that I would like to pose a question: is there a need to enunciate a National Security Policy as ‘state policy’ so that there is a fundamental multi-partisan broad-based consensus on a set of policy measures that need to be protected from ad hoc whims and need to be implemented regardless of the government in power. Although many things come within the rubric of security outside of what is included in the traditional security sphere, consensus should be garnered on some key projects and plans of strategic interest to the country and its people—water reservoirs, plans for ensuring energy and food security, resource mobilization plans, curtailment of expenditure, polices to signal confidence to potential investors and key directions with regard the state’s redistributive role.
Pakistan’s unique problems demand equally unique solutions that have to be indigenously driven and led by credible leadership. There isn’t a multilateral cookie cutter approach to such changes, neither is there a comparable precedent which can be mirrored. Beyond tinkering at the margins, one of the tests of Pakistan’s leadership today is to enable a consensus on a holistic National Security Policy and use its strategic leverage in a globalized world to secure support for its implementation.
The author is the founder and president of the NGO thinktank, Heartfile. sania@heartfile.org
National Health Policy 2010
Published in The News International on March 22, 2010:
The Ministry of Health has stepped up efforts to enunciate the National Health Policy 2010 and bring the process, which commenced with the initiation of a Health Policy Task Force in 2008 to fruition since the availability of donor resources has been made conditional on pronouncement of a health policy.
Development of a new vision for a health policy is a complex process in Pakistan’s context for a number of reasons. Pakistan’s mixed health system has many systemic flaws, therefore, a reform agenda must be implicit in a health policy. The diversity of health systems domains and the range of health actors and institutions need to be factored into consideration in the process. The complexities of health governance, multiple funding sources for health, and external drivers that impact health need to be addressed while framing the policy. Directions for service delivery arrangements that can enable universal coverage for a set of interventions have to be articulated within the rubric of which the public-private-interface dimension has to be addressed. Then there are policy positions with regard to health information systems, health workforce at various levels, and the mechanisms and means of health financing, which need to be stated. Broader structural dimensions impacting the health system—decentralization, mechanisms of social protection, labour market interventions and health’s entry points to reduce poverty—are other considerations. A health policy additionally has to be alive to the realities of globalization, disease security and health risks as a result thereof, the harmful effects of trade, and the aid effectiveness agenda.
Given the diversity of domains and the possible policy options within the remit of each, there is a risk that the policy may end up being a concoction of jargons stated as policy approaches. If the draft, currently under preparation ends up with such a construct, an opportunity will be missed.
As a key social sector instrument, a ‘national’ (federal) health policy must have certain features in order for it to have any meaning in the context of some fundamental shifts, which are taking place at the broader state level. There is a movement towards judicialisation of rights and the Constitution is being amended; a call for universal coverage reform could be linked to constitutional changes. Provincial assertions for a more autonomous status are now pressing and indications that the federal government might finally relent are evidenced in the National Finance Commission Award 2010 and statements that the Concurrent List might be scaled down. This, therefore, could be the right time to re-examine the federal government’s role in the health sector. Moreover, there is pressure on the government to scale down recurrent expenditures in order to reduce fiscal deficit and an International Monetary Fund-conditionality in line with this has recommended that the ministries of Health and Population be merged. If this is being taken seriously, as official statements indicate, the enunciation of a national health policy—and a population policy, which incidentally is being framed at the same time—is the right opportunity to cascade political intent into a policy instrument. Furthermore, as the fate of the district government system is now fully in the hands of the provinces, it doesn’t make sense to give explicit across-the-board guidance on how services delivery will be managed.
It is well known, constitutionally decreed and frequently recalled that health is a provincial subject, but when it comes to the pronouncement of polices and structural decisions, a top-down approach is adopted with the tendency to micromanage, implicit. If that is adopted this time round in the case of the national health policy, the whole purpose of the exercise will be defeated. There has been a long standing history of federal heavy handedness in health. Now is the time to remedy that.
That said, there are some important purposes that a national health policy can achieve and areas where the mandate and the comparative advantage of a federal role in health can be capitalized through a federal policy instrument. Three areas are being outlined in this regard.
One, since resource mobilization is predominantly a federal mandate, a federal policy should deliver a plan for incremental increases in public sources of financing and revenue earmarking for health based on a provincially-agreed per-capita cost, which is considered adequate for delivering essential services. The policy could integrate allocations from the general revenue pool to support common health objectives, which is currently not the case. A federal fiscal tool could develop incentives for provinces and districts to enhance health allocations. Rather than micromanaging the type of insurance schemes to be pursued, the federal government could signal an intent to broaden the base of pooling through legislation, whilst leaving specific options open for provinces to pursue. Most importantly, the fiscal strategy central to the policy can be an opportunity for the federal government to off-load its service delivery responsibilities inherent to administrating hospitals and the national vertical public health programs, which have crowded out the space for normative work—a ministry’s core responsibility.
Second, a national policy must spell the principles of service delivery, in addition to the broader principles of a health policy. Several management reengineering experiments are being conducted by health departments of various provinces, and other state institutions. Pakistan’s primary healthcare infrastructure is a thriving laboratory. These innovations can only bear dividends if evidence is factored into planning in line with stated principles to ensure that state investments are targeted to serve the equity objective. A national policy assumes great importance in negotiating these principles and safeguards, which can then become benchmarks for service performance nationally, whilst fully giving provinces the prerogative to choose locally-suited service delivery options.
Thirdly, there are important federal roles in health, where the policy must state its position loud and clear. The strategic area of consolidating evidence and information and bridging gaps in Pakistan’s health information system is one of them and is an increasingly important area in view of threats from emerging and re-emerging infections in Asia. Implementing globally binding agreements, the Framework Convention on Tobacco Control and the International Health Regulations 2005 is another important area as are the myriad of policy dimensions relevant to trade in health and coordinating donors’ contributions. Medicines and Workforce policy in health is a known federal forte. The federal government also has an important role in health regulation with dimensions relevant to regulation of price, volumes and quality in the domains of service delivery, medical education and pharmaceuticals. Its regulatory role becomes important because of provincial limitations in capacity in these areas.
The policy must be clear on these aspects with regard to what the government will do next. A clear position on the Drug Regulatory Authority is a case in point and directions with regard to other regulatory domains, where the government does not have institutional arrangements to begin with are equally important.
In sum, therefore, a health policy must evolve in the context of the structure of Pakistan’s federation and constitutional stipulations. It must clearly signal policy positions with regard to the core, but difficult issues related to the federal government’s role in health with clarity and state how the Ministry of Health will transform its own capacity to cope with these issues. Operational details of relevance to service delivery must be left to the provinces. However, relegating responsibility to the provinces is not a guarantee of success especially if the current institutional capacity of the provinces and districts does not transform, both from a performance-effectiveness as well as transparency perspectives—Pakistan’s health policy woes will, therefore, unfortunately, not come to an end with pronouncement of the national health policy 2010.
The writer is the founder and president of the NGO think tank, Heartfile. E mail: sania@heartfile.org
Federal Bureau of statistics and the draft bill
Published in The News International on March 22, 2010:
The evidence generating institutional arrangements of a state qualify to be its fourth pillar, since evidence constitutes the basis of decisions in every state domain. Within this context, the draft bill to make the Federal Bureau of Statistics (FBS) an independent body, scheduled to be presented in the next parliamentary session assumes great importance. The bill uses grant of autonomy as an instrument to create a new agency—Pakistan Bureau of Statistics (PBS)—by restructuring and reorganizing three existing data collection organizations. The rationale and design for this approach has been published in a paper titled “Challenges in data collection in a developing country: the Pakistan experiences as a way forward” in the Statistical Journal of the International Association for Official Statistics (IAOS) and has been authored by a former Secretary of the Statistics Division.
Legislation in this area is of tremendous significance, which is why the context, connotations, limitations, implications and imperatives related to this bill must be understood.
Before a few points in relation to these aspects are discussed, it must be appreciated that official statistics are one source of data in a national information system. The overall purpose of this system is to generate and communicate evidence for planning, monitoring and reviews related to decision-making.
There are two constraints in relation to the use of evidence in relation to state policy and strategy in Pakistan. The first is paucity of usable evidence whereas the second impediment is the culture of decision-making based on convention, personal interests, anecdotal evidence, and/or political expediency. While the determinants of the second constraint are embedded in a complex interplay of governance and over-arching political factors, the first constraint can be overcome to a large extent by strengthening the institutional pillars of a national information system, of which a statistical agency is a part.
Based on information in the public domain, it is evident that the bill has some useful clauses. For example, merging FBS with the Agriculture Census Organization and Population Census Organization can help reduce recurrent costs and eliminate duplication. User’s council mandated through the legislation can be an inclusive approach, whereas the focus on capacity building, career planning of professional staff, upgrading of skills, and the creation of a fund is, at the least, a needed recognition of the importance of these dimensions. However, the extent to which the current resource realities will enable progress in this direction remains to be seen.
In addition to what is being addressed through the bill, some other considerations also merit attention in relation to the new agency. The first point relates to the mandate of the PBS. There are many other state agencies other than the three that are being merged, which engage in data collection through instruments that are duplicative. There are other sources of information in the procurement, public expenditure tracking and e-governance channels within the state system that can provide useful evidence. Moreover there are other sources of valuable information within the data systems of the industry, businesses, private providers, social enterprises, distribution and retail networks, which largely remain untapped as sources of information. The new agency must be mandated and empowered for better data collection, collation and coordination so that consolidation of ad hoc and standalone data systems are enabled.
Secondly, the purpose of a statistical agency in a resource constrained country should not solely be to collate data but also to consolidate information, perform triangulations and interpret and analyze data, and ensure its timely relay to the right decision makers. Existing capacity constraints are important with respect to all these desired roles; these gaps will be further widened as has been illustrated in the IOAS paper. Appropriate competencies, skills, and capacity are a must to ensure quality in data systems. The capacity and quality constraints within the PBS also assume importance since the capacity of ministries and government departments in terms of data analysis is particularly weak and it does not seem plausible to invest in standalone programs within their domains given the current resource constraints. Appropriate capacity is also needed to remedy the existing information discrepancies within the state system. Shortcomings of the methodology adopted to document the size of Pakistan’s economy is particularly illustrative in this regard. It is only through appropriate capacity that a transformational change can be brought to address prevailing gap in the current information systems.
The capacity imperative is also driven by the need to ensure compliance with international standards and maintain data quality to enable international comparisons in today’s globalized world. Previously, investments were made in a training institute allied to the FBS, which can be used as an institutional entry point to step up capacity building efforts within the PBS. Two of the bilateral donors have a particular interest in strengthening capacity and have committed resources for this purpose. Their role should be strategically harnessed for capacity strengthening within the FBS. However, in tandem, safeguards must be built against brain drain through appropriate retention policies.
Thirdly, the role of the technology must be brought to bear and should be fully leveraged in developing and maintaining a national information system. Pakistan’s telecommunication network, in particular, mobile telecommunication has enhanced significantly in the past decade and has wide coverage, but is not being fully capitalized. Similarly, very few organizations have IT enabled systems for collecting data and the potential within innovative solutions, like modified versions of low-end mobile telephones and palmtops to collect data from the field remains untapped. State agencies usually do to make optimal investments in IT infrastructure for collection, aggregation, and analysis of data and to enhance connectivity within data systems. Similarly use of Free and Open Source Software remains untapped. The new data agency must make the right linkages with the Ministry of IT and other government agencies that have IT enabled systems to capitalize on the existing infrastructure so that information can be used for generating evidence in a timely manner. In a globalized world appropriate use of technology can also enable real time surveillance in many areas, for example, price surveillance for procurements and disease surveillance for timely action. These are now becoming imperatives in a global village within which Pakistan must learn to survive.
Lastly, the institutional design of the envisaged PBS from the point of view of its governance arrangement merits attention. The FBS is currently under control of the government and there are many sad stories of data tampering, the details of which I do not want to get into. The ethos of statecraft dictates that any evidence generation agency should be free from the controls of those who can have a vested interest in maneuvering data and information. Therefore, an independent autonomous design is envisaged as a safeguard against influence. The bill structures autonomy in principle. However, past experiences of ‘autonomous’ agencies show that grant of autonomy is often incomplete in terms of administrative and financial controls and that the government often tends to keep loopholes active, which enable them to exercise influence when needed. If this manner of ‘autonomy’ is structured again, the whole purpose of the bill will be defeated. The new agency must also take a policy decision to place all the raw (meta) data files in the public domain. This can be one of the most important measures to guard against data tampering.
With attention to the right leadership and technical capacity, the needed transformation in the working of PBS can be enabled. However, beyond the bill and PBS, the state machinery must garner an unyielding political and institutional commitment to base decisions on evidence and institutionalize rational accountability of the decision-making process.
The writer is the founding president of the NGO think-tank, Heartfile. sania@heartfile.org
Scaling up Financing for Health
Nishtar S. Scaling up Financing for Health. Lancet 2010;375:983 and can be accessed at http://www.who.int/bulletin/volumes/88/1/09-067868/en/
Women through the governance lens
Published in The News International on March 08, 2010:
Although effective governance—or the lack thereof—has an impact on every aspect of our societal, social and economic lives, nowhere is its imprint more vivid than in determining the status of women in a society. This comment uses the International Women’s Day, which is being globally observed today as a peg to briefly outline the linkages. This year’s theme of International Women’s day entitled “Equal rights, equal opportunities: progress for all” is particularly relevant to governance, since upholding women’s political, economic and social rights and striving towards achieving equity and equality of opportunity in a national political context cannot be ensured without effective governance.
Before we examine the relationship, let us be reminded that the status of women in Pakistan is fraught with an ironic and highly polarized paradox, implicit within which are many inequities and inequalities. These are evident in many areas. One the one hand, women are well represented in the parliament; but on the other, exceptions notwithstanding, this largely represents an extension of elite and feudal capture. Professional institutions of higher learning have 50% or higher enrollment of women; but at the same time, there is a literacy gap of 45% between men and women and the opportunities for rural women’s education remain elusive. Similarly, we see a growing number of women in traditional male-dominated professions such as engineering, law, medicine, business, the police and the military. But alongside this trend, nationally representative labor market statistics speak of gender discrepancies, under-remuneration, systemic impediments to mainstreaming women into the country’s workforce and restricted employment options outside of the informal sectors for socially marginalized and disadvantaged women. Furthermore, it can be argued—and correctly so with reference to a segment belonging to the higher social stratum—that women appear freer than ever to express themselves in the choice of appearance, speech, clothing, arts, entertainment and that they are becoming increasingly progressive, empowered and globalized. However others and in their close geographic midst are relegated to the strictest confines of purdah, isolation and disempowerment. Moreover many Pakistani women of today enjoy a better status than most Middle Eastern Women. But at the same time these trends, which are true for a minority, haven’t changed some of the deep-seated social behaviours and fundamental prejudices against women, which translate both into discrimination as well as some of the severest forms of violence.
Some may argue that violence against women is globally pervasive. Indeed it may come as no surprise that 70-90% of women in Pakistan encounter domestic violence and that there are an estimated 8 cases of rape every 24 hours in view of similar, and sometimes worse statistics in other countries. However, what is unfortunately unique to Pakistan is the prevalence of some horrific crimes.
We generally tend to attribute all these abhorrent practices to our tribal and feudal traditions and norms and to the systemic subordination of women vis-à-vis men. That may well be the case to some extent. However, what is not fully appreciated is the role that many other systemic factors play in perpetuating these traditions. Poverty, illiteracy, and social exclusion have a chicken and egg relationship with organized vested interests, of which feudalism is a part, and which promote state capture. A democratic dispensation should be able to break through the strongholds of vested interest, but unfortunately it sometimes helps to strengthen it.
If the state was governed effectively over the years and Pakistan had sped on the road to development with its economic and social benefits accruing to its population, as has been the case with many Asian tigers; if the state had delivered education universally to its population and if an honest hand of the government had weakened the organized vested interests that form the bedeck of undesirable tribal and feudal traditions, perhaps heinous crimes such as honor killings and burying alive, would not be condoned as social customs and tribal traditions today. In the absence of these fundamental attributes, which determine the status of women in a society, the impact of legal reforms to improve the status of women introduced by successive governments has been, at best, marginal. Similarly, standalone gender empowerment programs, measures to enhance access of women to financial services, and others for skill enhancement have had limited impact whist the adverse fundamentals remain unchanged. This is the first, and perhaps the most illustrative of the pathways through which failures of governance can be shown to impact the lives of women. Here it must be appreciated that the term governance is the subject of many interpretations, but in the current sense it is being scoped to the policy making and implementation realms and use of public resources and regulatory power.
The status of women and issues implicit within it, also underscore the importance of another governance impediment—one that relates to ensuring compliance with stated policy norms and standards and enforcement of laws. In theory, Pakistan ensures respect for women’s human rights and fundamental freedoms, as is evidenced by the ratification of many global conventions and declarations. These include the Universal Declaration of Human Rights, the Convention on the Elimination of all forms of Discrimination Against Women (CEDAW) and the UN Declaration on the Elimination of Violence. Pakistan’s Constitution has many provisions, which stipulate that “All citizens are equal before the law and are entitled to equal protection of the law” and that “There shall be no discrimination on the basis of sex alone” Article 25(1) and 25 (2) respectively. Article 35 specifically states that “steps shall be taken to ensure full participation of women in all spheres of national law”.
Several laws are additionally in place, including the Protection of Women (Criminal Laws Amendment) Act 2006. Experts are of the opinion that although all the discriminatory provisions embodied within earlier statutes were not addressed through this statute, it is nevertheless a step in the right direction. Recently the Women at Workplace Act 2009 has been enacted which aims to “protect women from harassment and (is intended to) make them feel more secure”. In addition laws are in place to ensure women’s right to inheritance—an important element in women’s socio economic and political empowerment.
However, there are two issues with the implementation of these laws. One set of issues is generic to implementation of laws in Pakistan. Secondly, the fact that regardless of what the statutes may stipulate, these are conditional on social norms and traditions, which the vast majority of women in the society have to bear with. These issues are further compounded by the biases against women in the criminal justice system—but more important than that poor performance of the justice system and the relative intransigence with which it dispenses justice to women.
In sum, the status of women is deeply linked with many elements of the society—legal, political, religious, economic, and cultural. Governance can play a key role in shaping most if not all of the societal characteristics through ensuring respect for women’s political, economic and social rights.
So whilst enlightened women’s groups draw attention to horrific crimes and discriminatory practices against women—honor killings, live burials, disfigurement by acid, stove deaths, and other undesirable practices, such as childhood marriages, watta satta, vini, marriage to the Quran—to mark international women’s day we should be reminded that quantum leaps in addressing these challenges can only be made with slow and steady structural solutions.
The writer is the founding president of the NGO think-tank, Heartfile. sania@heartfile.org
Choked Pipes — Reforming Pakistan’s Mixed Health System
Nishtar S. Choked Pipes — Reforming Pakistan’s Mixed Health System (invited editorial). J Pak Med Assoc 2010;60(4):252-3 and can be accessble at http://www.who.int/bulletin/volumes/88/1/09-067868/en/
Civil service reform revisited
Published in The News International on February 27, 2010:
The International Crisis Group’s Report on Civil Service Reform has sparked conversations around the need and potential avenues for restructuring Pakistan’s civil service. This, however, is not the first time that a report on the subject has been made public. Ever since the country’s creation, more than thirty commissions/committees have been constituted and convened to frame normative guidance relevant to this area. A detailed account of past efforts has been summarised in the report of the National Commission for Government Reform (NCGR), the most recent of these initiatives, which was tasked with the responsibility of developing recommendations to reform the executive branch of the state. The report states that previous recommendations have “been neglected, were partially implemented or distorted beyond recognition”.
The denotation of civil service reform in the reform jargon is not an isolated or a defined restructuring measure, but a set of locally-suited interventions centered on restructuring laws, codes of conduct, remuneration norms, institutional devices, and policy frameworks. Given this diversity, priorities for action and a plan for phasing reforms are important. In order to do that, the key problems with Pakistan’s civil service must be appreciated as a starting point. Broadly, these fall into three categories.
First, is the ‘colonial-contemporary lag’. Pakistan’s civil service has been modelled on the colonial system, where the bureaucracy was geared towards command and control. In the district-divisional system, a single person was empowered to collect revenue, dispense justice, exercise administrative control, assume responsibility for delivering services, and allocate land rights—in other words, absolute control. Comparable prerogatives existed at the secretariat/divisional and departmental levels. This model served the purpose of keeping citizens sub-ordinate. The realities of the state are very different today. The government must not ‘rule’ but ‘govern’ in a democratic system; it must reconfigure its capacity to harness the resources of the economy towards the goals of development and learn to engage with the private sector in areas which were previously thought to be in the ‘public domain’. Although successive governments have attempted to make some changes to be responsive to these realities, those measures haven’t borne fruit. The local government system, which was meant to be a departure from the post-colonial style of administration, wasn’t able to deliver on its premise — its current restructuring also offers little hope for reform. Frameworks for public-private partnerships, despite being in existence, have not been functioning because of institutional wrangling. And as for institutional performance, it is ironic that the most important organisation in the country — the government — upon which the functioning of almost everything else hinges, has not learnt from contemporary organisational management and business processes, and remains aligned on antiquated paradigms of ruling, which put the state at a disadvantage with respect to domestic realities and meaningful global existence.
The second problem relates to limited understanding of human resource management. In the public sector, human resource management is generally considered as being synonymous with the creation of posts, placement of staff, and disciplinary action, and is, as such, often used as a lever of power. Human resource management usually does not appear to be a priority and the capacity to plan in this area often does not exist within ministries. The environment is additionally not conducive to fostering improvements in performance. The system does not reward high performers, in general. Rules and regulations governing administrative and financial prerogatives are overtly cumbersome and tend to centralise decision-making. This is particularly relevant to operational decision-making, in relation to domains where strategic decisions have already been made at a higher level. A case in point is the re-seeking of permission for activities stipulated under approved PC 1s, which accounts for unnecessary delays and ingrains inefficiency.
The third problem and one which compounds the other two relates to the space that exists for institutionalised manipulation. Over the last several decades, numerous changes have been made in the structure of civil service in the guise of ‘reforms’. Some, as stated in the International Crisis Group’s report, have “weakened the constitutionally guaranteed protection of employment that had previously shielded the bureaucracy against political interference”. Other ‘reforms’ were aimed at ideologically reorienting the bureaucracy, entrenching military’s presence in the bureaucracy, whilst still others eroded neutrality at all levels of the administration. By-and-large, administrative restructuring was used as a tool by many rulers for personal gains and political patronage in order to consolidate their bases. Over the years, therefore, a culture emerged where civil servants were patronised and promoted, not on merit but on perceived loyalty to their respective unnamed political affiliations. Civil servants have responded to this in many ways. Whilst a majority resents this trend and still tries to operate honestly in a politicised environment, others feel unprotected due to the fear of undue accountability and choose to defer decisions whilst still others — and a growing number — tend to please their superiors rather than being responsive to citizens’ needs. In doing the latter, they become party to politically expedient decisions that have limited grounding in evidence. These institutional behaviours promote a culture where a range of ethical, intellectual, procedural, and financial forms of malpractices are becoming pervasive in the system.
As a result of all these factors, Pakistan’s system of civil service — which has yet to conform to contemporary realities after 63 years of the country’s existence — has fallen prey to exploitation, both from within its ranks as well as from outside as a result of collusive behaviour of non-bona fide entities within the political system and the private sector. And hence malpractices and inefficiencies are getting institutionalised. Poor management and lack of accountability exacerbate malpractices, whereas on the other hand, there may be a disincentive for administrators to strengthen management and mainstream mechanisms that compel accountability. Both these factors complement each other in a vicious cycle.
Civil service reform, therefore, cannot be achieved through isolated technocratic solutions; the latter can only be useful if the broader political determinants are conducive.
Measures to reform the civil service are further deeply interlinked with the collective organisational structure, procedures, protocols, and sets of regulations to manage government’s activity — in other words the prevailing system of bureaucracy. There are many unresolved questions of relevance to Pakistan in this space that need to be addressed: the relationship of the federal, provincial and district governments, the question of provincial autonomy, the fate of the many parastatal agencies, which cause the fiscal system to hemorrhage; the institutional relationships with respect to policy making, regulation and implementation; the structure of pre-service, in-service and ongoing training and capacity building; the government’s supporting infrastructure, such as e-governance, and so on.
Reform of civil service, implicit within which is a set of measures to restructure recruitment, retention, training, career progression, capacity building, remuneration, and accountability frameworks, therefore, cannot be taken in isolation and needs to be framed in the context of this entire structure, which determines how a government functions. The feasibility of these changes additionally has to be locally determined, as there isn’t a cookie-cutter multilateral framework that can make reforms work in any setting. Rather than reinventing the wheel at the cost of the taxpayers’ money, it appears most logical to use the recommendations of the NCGR to develop a multi-partisan consensus on the way forward, and analyse the resource implications of an agreed plan, based on which a phased approach can be adopted.
Pending long-term solutions, the single most important measure is to let merit and performance take over. There are many champions within Pakistan’s bureaucracy whose potential can be harnessed through this approach.
The writer is the founding president of the NGO think tank, Heartfile. Email: sania@ heartfile.org
Separation of powers
Published in The News International on February 20, 2010:
The potential standoff between government and judiciary has finally been averted. Process-related concerns notwithstanding, the saga’s culmination appears to be a product of sound technical advice, heed to provisions of the constitution and a process of consultation. These attributes of governance will surely pay dividends whenever they are mainstreamed in decision-making in matters of state.
There is a lesson to be learnt here. But as always, reflections are becoming centered on conspiracy theories, power struggles, personal rivalries and institutional divides–in other words, power politics. By contrast some systemic considerations related to the implications of the averted standoff for state governance and its determinants have not featured prominently in discussions. This comment aims to underscore the importance of these factors.
The matter was centered on prerogatives of institutions, which brings to the fore the question of ’separation of powers’. The purpose of separation of powers is to foster institutional checks and balances, as it is only through these that safeguards can be built against potential abuse of power. Failure to institutionalise these simply creates opportunities for tyranny–whether it is in the shape of traditional dictatorship–military rule–or absolutism in the guise of democratic rule.
There are many examples over the course of the last 63 years where the authority of decision-making has been in the hands of one person in Pakistan, both during military and civilian reigns. In these situations, power has been deliberately and/or inadvertently abused and the legitimacy and sustainability of power grabbed by the executive could not be hindered, as a result of lack of separation of powers. This trend continued to prevail because powers have traditionally been ‘fused’ and the checks and balances, which could act as safeguards against abuse of power could not be asserted and in many cases, stood blurred.
We need to understand why this has been the case in the past, why this pattern appears to be changing now and where the impediments to change stand. Understanding the concept of separation of powers in Pakistan’s context is important in this regard.
In Pakistan as in any other constitutional democracy, the powers of the government are meant to be divided so that the legislature makes laws, the executive authority carries them out and the judiciary operates independently. In any constitutional democracy, a system of checks and balances is inherently implicit, and that is why powers are meant to be separated.
The judiciary is meant to exercise checks on the parliament. The power of judges to review public laws and declare them in violation of the nation’s constitution serves as a fundamental check on any potential abuse of power by the government. The constitution has a supreme status, which means that any law that violates the constitution or conducts that conflict with it can be challenged and struck down by courts. This prerogative of the judiciary has not been widely exercised in the past. However, with increasing trend towards judicial activism, the judiciary has increasingly made use of this privilege. So in its ruling on the legal validity of the National Reconciliation Ordinance (NRO) and terming it void ab initio for being ultra vires of the constitution, the judiciary exercised a fundamental check. Striking down the recent notifications as being in violation of the constitution is also a check on the executive’s authority and must be perceived in the same spirit.
The judiciary can also exercise similar checks on the executive. However, some of the recent ‘checks’–e.g. the suo moto actions with regard to setting sugar prices–are controversial, as there are many economic considerations determining price increase. Shortcomings in governance, though a proximate cause, are not a violation of the constitution, per se.
This aspect notwithstanding, the recent trend towards independence of the judiciary is a positive trend and one that holds promise of impact with regard to institutionalising checks and balances, provided ‘impendence’ does not transcend into ‘judicial imperialism’, as an expert has recently emphasized. Additionally, in order to fully realise its impact in a sustainable manner, two things must be ensured. One, de-politicising the superior judiciary and two, elimination of graft at all levels through reform of the judicial system.
The other system of checks and balances relates to the check of the legislature on the executive. There are two complicating factors in this regard–one generic to Pakistan and the other inherent to parliamentary forms of government, in general. Each of these creates a separate imperative for systemically ingraining checks and balances in Pakistan’s context.
Firstly, the power of the executive has been vested either in the president or the prime minister at different times in Pakistan. The 1973 Constitution and the 13th and 14th Amendments greatly empowered the prime minister whereas the 8th and 17th Amendments shifted power to the president’s office. Striking the right balance has therefore been a major bone of contention. Having a presidential chief executive in a parliamentary system creates a level of complexity and undermines the ability of the legislators to exercise checks on the executive. The solution to this lies in fashioning structural provisions of the constitution to separate powers.
Secondly, the other complicating factor with regard to separation of powers is inherent to the differences between presidential and parliamentary forms of government, which are the two ways in which executive authority is organised in constitutional democracies. Separation of powers, also known as trias politica, a model for governance in democratic states, is a feature inherent to the presidential system whereas ‘fusion of powers’ is characteristic of parliamentary systems. In the latter, the executive which consists of the prime minister and the cabinet are drawn from the legislature. Given this fusion, the role of an independent judiciary becomes all the more important in a parliamentary system.
The solutions to the lack of parliamentary oversight on the functioning of the government are not confined to amending the constitution. Overall systems of accountability need to be revamped to ensure that institutional instruments and arrangements are in place to enable direct and indirect political, administrative and financial accountability–both ways, involving the legislators and the executive. In doing so decision makers must scope beyond the current narrow ambit of accountability, as is being envisioned in the Accountability Bill. In order to ingrain appropriate checks and balances, many relevant institutions and instruments need to be restructured to address administrative dysfunction, mismanagement and political manipulation–all of which are pervasive in the system.
In sum therefore, two key instruments need to be reshaped in order to institutionalise a system of checks and balances between the three pillars of the state; one, the Constitution and two, a holistic accountability framework. The potential within these norms–if appropriately cascaded into implementation–to shape the destiny of this country must not be underestimated.
The writer is founder-president of the NGO think tank, Heartfile. Email: sania @hartfile.org
The taxonomy within FoDP
Published in The News International on February 13, 2010:
Members of the forum of Friends of Democratic Pakistan (FoDP) have been convened for the fourth time since the announcement, which led to the creation of the forum in September 2008 on the sidelines of the UN General Assembly. Whilst the initial meetings in New York, Tokyo and Istanbul were framed in the traditional mode with bilateral and multilateral development agencies and countries dominating, the fourth has taken a slight deviation from what is the norm in diplomatic-development-engagement in Pakistan’s history to also focus on public-private partnerships. This was evident in the theme of the fourth conference, which was hosted by the Government of UAE and was convened by Pakistan’s foreign office on January 26 in Dubai.
The relationships that determine the structure of FoPD and its diplomatic connotations are somewhat tenuous. The rate at which pledges have realized are a further bone of contention. These limitations notwithstanding, FoDP can be a useful forum if friends’ support is strategically harnessed.
Through this comment I would like to flag a taxonomy of opportunities that could be explored through this arrangement. Essentially, there are three areas of engagement within the FoPD’s remit. For each, there are a different set of stakeholders, relevant institutional points of interface, a set of objectives that can be relevant for persual and imperatives with regard to what the government needs to do. Given this diverse landscape, there are often overlaps. It is important to bring clarity to the dynamics within each space.
The first is the traditional space of bilateral and multilateral assistance. Here, donors usually want to contribute towards achieving specific targets or outcomes. The government on the other hand, would rather have aid ‘on-budget’ to ease its fiscal constraints. However, the pledges so far, under the rubric of FoDP have not been fulfilled and the word has it that donors are skeptical about transparency within the government system, and are hence, holding back from disbursing or allocating monies. The challenge for the government within this space of engagement would be to signal confidence by demonstrating transparent use of resources and clearly laying out areas for which resources would be utilized. In this regard, the government can offer third party-audits of projects developed through funds from FODP countries. Line ministries, the Planning Commission and the Economic Affairs Division can work together to outline areas, develop feasibilities and maximize mobilization of resources through existing and new windows, with particular attention to debt swaps, amongst other instruments. However, the overarching objective should be to channel assistance to help strengthen domestic systems and mechanisms with a view to ultimately transition away from support.
The second point of interface is with the investor. Theoretically speaking, a diplomatic effort can help bring investments into Pakistan. On the one hand, there are many odds against investments given the overall law and order and security situation. However, by far the greatest enemy of investments is uncertainty of policy, and gaps in mechanisms to facilitate incoming investments. Lack of efficient mechanisms to dispense justice are a further complicating factor—debacles such as a recent real estate crisis in Karachi do very little to inspire confidence in that respect. If Pakistan wants to use the governments on the FoDP forum to access their business communities, and present the country as a destination for investments, then it will have to make the environment facilitative for businesses to operate. Here we need to be mindful of the fact that there are competing areas in our geographic neighborhood, where economies of scale, one-window operations and better governance are far more appealing to the investor. Improving governance is key to catalyzing investments—donors can also provide assistance within this space by supporting public sector reforms. However, in addition, there is also the need for mobilizing other stakeholders. Beyond the Board of Investment, honorary Consul Generals, bilateral business forums, and currently operating business and trading communities are important in this regard.
Public-private partnerships (PPP) present the third point of engagement. In addition to public-private resonance, an ideal PPP should present an opportunity for investment whilst at the same time have a public good character through protecting public interest. These arrangements can be defined as ‘cooperative ventures, or risk sharing relationship between the public and private sectors, built upon the expertise of each partner that best meets clearly defined public needs through the appropriate allocation of resources, risks and rewards’. Through this approach, a number of diverse interface arrangements can be created. On the one hand, private money can be used to undertake projects normally in the realm of the public sector, or public money can be used to undertake projects with management expertise of the private sector, on the other. In between there are many hybrid models that combine a bit of both. In fact, in some public-private ventures, the contribution of the government can be in the form of real estate, tax and regulatory incentives, permissions, licenses or subsidized debt. The latest PPP Policy which has been recently approved by ECC provides the over-all framework for all these arrangements.
Public-private partnership was the theme of the Dubai conference. There is indeed significant potential within these models to contribute towards meeting infrastructure needs of the country, but that potential has not been tapped, despite the existence of an institutional backbone that could have played an enabling role, if it was empowered.
There is need for massive investment in infrastructure in Pakistan. According to the Asian Development Bank, the government needs US$ 13 billion annually over the next 5 years in order to meet its infrastructure requirements and be able to generate and sustain a desired growth rate. The government’s spending on infrastructure is nowhere close to this—Rs. 646 billion for the current fiscal year—and will be further compromised with the impending 40% cuts in the Public Sector Development Program. Pakistan, therefore, has no option but to resort to the PPP route. According to the Infrastructure Project Development Facility (IPDF)—a company established by the Ministry of Finance—the existing PPP opportunities in infrastructure in Pakistan amount to around US$ 2 billion. These exist in various sectors: mass transit, communications, highways, railways, ports, logistics, and social sector infrastructure. Additional opportunities also exist in power and energy sectors.
Whilst PPPs are an attractive route to attract investments, it must be recognized that these are complex arrangements. On the one hand, these entail a transformational change in the manner in which the government envisages undertaking infrastructure projects; this has implications for human resource capacity and changes in institutional norms, in general. On the other hand, it entails a specific role for several government agencies.
The Planning Commission needs to have the capacity and the mandate to define projects, which should be taken through the PPP route. For the transaction structuring phase, the role of IPDF becomes important. In addition a PPP law needs to be enacted and windows for viability gap funding need to be initialized. It is only once these gaps are bridged that the FoDP form can be helpful in identifying potential partners and contributing towards project development.
In sum, therefore, there are three points of engagement with stakeholders within the space of the FoDP’s remit, where objectives, stakeholders and institutional points of interface need to be clearly defined. Most importantly, beyond these areas, the Forum must be capitalized to secure better market access and debt forgiveness. These can have a more pronounced and sustained impact on development compared with traditional modes of assistance.
The author is the founding President of the NGO thinktank, Heartfile. E mail: sania@heartfile.org
A poor man’s woes
Published in The News International on February 06, 2010:
The poor man is under tremendous stress as a result of numerous economic hardships including high unemployment, inflation, scarcity of essential commodities, and limited ability of the state to target welfare services. These hardships often prompt those who hold welfare of a common man close to their heart to question the relevance of issues that dominate current national debates — for example, constitutional amendments, the Supreme Court’s judgment on the NRO, power relationships between the pillars of the state, the accountability bill and issues of internal sovereignty — in relation to alleviating the sufferings of a common man. One particular email received subsequent to the publication of my January 5 article in these columns raises the same point. The sender raised a question and I quote: “Do you think Fazal Chacha who, along with his wife and three children is dying of water-borne diseases, is really worried about or concerned about sovereignty or the Constitution?” It is in response to such notions that I want to elaborate on the implications of restructuring state functioning at the broader strategic level for the life of a poor man.
We often think of alleviating poverty by meeting individual needs. The importance of this approach should not be underestimated. Food, clean water, security and shelter are the literal requirements for human survival and must be provided, where needed. However, it must be appreciated that the levers that determine their delivery are oiled by the effectiveness of overall governance, which is where broader strategic measures assume importance.
The compassionate approach to poverty alleviation, which focuses on the basis of giving — money more than time and skill — and which gets organised as philanthropy and Zakat is important in its own right. But compassion alone doesn’t help the poor man in the long run. Beyond giving, structural approaches to poverty alleviation are also important. These include sustainable government subsidies, income support programmes, safety nets, service delivery solutions by localised NGOs, vocational training, skill enhancement, labour market interventions, gender empowerment programmes, microfinance, other forms of access to financial services to support local entrepreneurship and augmenting domestic development resources with aid. These form part of the sustainable development approach and can be helpful in alleviating poverty by equipping and empowering individuals and communities to meet their own needs. However, even these do not reduce poverty. Beyond these, there is the need for sustained robust growth and for an honest redistributive hand of the government to ensure that the benefits of growth and development accrue to populations equitably.
Lessons from around the developing world show that massive poverty reduction and quantum changes in the lives of the poor is the result of overall robust and sustained economic growth through increases in capital — physical, human, and technological. Such a transformation is dependent on sound, consistent and effective policies, good governance, availability of financial services and an overall environment where peace, security, law and order and justice attract investments.
In such settings, the trickle-down of economic development becomes possible and benefits start accruing to the poor when economic freedoms, such as land rights and access to financial services are extended to the poor and when an honest hand of the government, fosters competitiveness and impartial oversight as a counter against organised vested interests at various levels.
The remedy to the poor man’s woes therefore does not lie just in compassionate solutions or isolated measures aimed at sustainable development and poverty eradication but in deploying these solutions in an overall context, where growth can be sustained. It is in setting this context that the construct of many parameters, which dominate national debates today assume importance.
Elaborating on the values of our Constitution as part of the post-NRO debates and structuring mechanisms to separate powers and ingrain constitutional checks and balances at the institutional level — an attempt at which is being made in deliberating on the construct of the 18th Amendment to the Constitution — assume great importance in this respect. If Constitutional stipulations could ensure appropriate power relationship between key decision makers in the past, if institutional checks and balances had been functioning, if there had been adherence to democratic principles of consensus-building, openness and transparency in decision-making, the complex geo-political conundrum with ethnic strife, multi-dimensional terrorism, organised crime and cult and mafia activity, as its key features would not be a threat to internal sovereignty today and we would not be paying the price of foreign policy decisions, made over successive decades. These threats to internal sovereignty, the uniqueness of law and order breakdown in the country, erosion of the institutional fabric with inefficient institutions as an outcome, and political instability are discouraging investments with dire consequences for the economy, as a result of which the poor man faces economic hardships.
Debates around the accountability law are critical. Lack of an institutional framework to compel accountability in the sphere of governance means that successive governments cannot be held responsible for failing to ensure economic security; for the inattention to ensuring water and energy security and for lack of investments in infrastructure critical for national development. In terms of economic progress, therefore, Pakistan lags behind its Asian peers as a result of which there are limited economic opportunities for the poor man.
The country’s mammoth debt burden has crowded out the space for development and the energy crisis is, and will continue to impact the life of the poor man in many ways. A range of decision makers and public functionaries are responsible for this but since there are no mechanisms to compel accountability, no one can be held responsible. Worst still, there are no guarantees that such behaviours and decision-making patterns will not continue to prevail — the present accountability law, even if its current weaknesses are addressed, has a strictly anti-corruption remit and does not cater to accountability at the broader governance level. Similarly, governance constraints, which have emerged overtime cannot check collusive behavior and have contributed to furthering state capture by the elite. The dire consequences of this vicious cycle affect the life of a common man in many ways. Elite capture, which can manifest as nepotism in hiring hurts a poor man when he gets sidelined from the job he may have otherwise qualified for, on merit. Elite capture of parliament affects the pattern of taxation, so whilst the agriculture sector and stock market remain outside the tax net, the common man bears the brunt by paying regressive indirect taxes. Similarly, cartelisation has recently exacerbated the sugar and wheat crises so the poor man suffers and spends hours in a queue with his daily wages being the opportunity cost. The opportunities for exploitation will not remain restricted to any specific sector if the current trends in governance and accountability prevail, but will, unfortunately, become pervasive across all segments of the economy. These are dangerous symptoms that will raise fundamental questions about the relevance of the state for a common man and can lead to widespread discontent, chaos and anarchy, which can be beyond the control of any government or political party to mitigate.
In sum, therefore, the life of a poor man will not improve and we will not be able to lift our masses from pervasive poverty until the broader structural state rubric, constitutional checks and balances, and a robust accountability framework are firmly put into place. These are founding blocks for a sound system of governance which is critical for growth, development, and welfare, all of which directly affect the life of a common man.
The writer is founding-president of the NGO think-tank, Heartfile. Email: sania@ heartfile.org
The healthcare bill 2009
Published in The News International on January 20, 2010:
Discussions around the Punjab Health Care Bill 2009 have intensified following some instances of alleged medical negligence in Lahore. The purpose of this comment is to clarify many policy and institutional implications of this bill in an attempt to avert a confrontation.
To begin with it is acknowledged that as the steward of the health sector, it is the responsibility of the government to ensure the provision of quality health services. Health being a provincial subject, it is also perfectly legitimate for the provincial government to legislate in this area. There is also a need for legislation in the quality regulation domain and imperative to create an institute focusing on quality, as this area has remained outside of the domain of planning. The need to bring the private sector within a normative framework is also acknowledged, as it is currently outside of the state’s purview.
It is also true that quality of care offered by the private sector is heterogeneous, that rampant malpractices are commonplace, that citizens and the bona fide elements within the private health market suffer at the hands of the non-bona fide private health actors, which are burgeoning at an alarming rate and that there is lack of awareness regarding the law of tort and the remedies available under it. In view of all these gaps, the move to regulate the private sector with a view to ensuring quality of services as an endpoint is perfectly understandable. But is the envisaged strategy to be pursued through the bill the right approach? I will draw insights from past experiences to support my opinion in this connection.
First, for any regulatory framework to be effective, the consensus of stakeholders is a prerequisite. Lessons from the failure of NWFPs’ policy on Institution Based Private Practice is instructive in this regard. This time around also the private healthcare community is not fully on board as is evident from the Pakistan Medical Association’s categorical call to confrontation at the outset and subsequent, post-hoc consultations. Even if a regulatory strategy is well conceived–and the present one has many gaps–it will be inherently constrained if there is no stakeholder ownership.
Second, the style of regulation and quality control measures to be adopted through this bill are intrinsically–and inadvertently–structured for failure. Current regulatory systems are plagued with institutionalized rent-seeking where low paid inspectors collude with private entities. It would be extremely difficult for any new regulatory institution to ensure a level of remuneration for regulators that could play a role in prohibiting such behaviors given the current fiscal constraints.
Third, even if resources are not an issue and a health care regulatory arrangement is created, the level of acceptability it will have in the present system should be brought to bear. From a broad health governance perspective, the creation of a Health Commission could represent the beginning of separation between three functions within the health administration. The commission could be mandated with a regulatory role, the Secretariat could retain a policy making function and implementation could be entrusted to the departments of health and the EDOs’ offices. In theory this is a desirable model, but it needs long-term consistency of policy direction and robust technical capacity to institutionalize such a change. There are inherent limitations in this respect and resistance to change from stakeholders who have a vested interest in maintaining status quo. The saga of the Drug Regularity Authority is a case in point where action has not been forthcoming since 2005.
Fourth, Pakistan’s history is replete with examples of ‘independent commissions’, which have not delivered on the intended premise. We tend to think of institution creation as an end in itself. We don’t structure the measures needed for institution building and often trade off design robustness in favor of structuring loopholes for controls. In fact some sections of the bill indicate an intent to factor-in discretionary powers, which can allow uneven application of the law at a later stage.
And finally, even if the government of Punjab created the ideal regulatory authority and even if had the money to do that, it must be remembered that institutions cannot be disconnected from their environment and that in isolation they are not a substitute for the many inefficiencies that pervade the health system in general.
It is therefore recommended that the government should reconsider its approach to quality regulation. Given the size and scale of the private sector and the nature of needed changes, a market harnessing form of regulation, which can incentivize the delivery of quality services appears the most feasible. The importance of this approach is that it can be mainstreamed at the same time as some other critically needed measures to harness the outreach of private providers. The latter are needed in Pakistan as 70 per cent of the healthcare delivery is by the private sector, whose potential to deliver public goods in health remains un-harnessed.
The decision to use private providers to deliver public goods in health entails the creation of a set of policy and regulatory norms. It is in tandem with these fundamental changes that incentives for quality can be built and with careful monitoring and oversight, can be successful in Pakistan’s complex environment. Coercive measures in isolation cannot be a substitute for the needed reform in the health sector.
The writer is the founder and president of Heartfile. Email: sania@heartfile.org
2010 — grand challenges
Published in The News International on January 11, 2010:
A review of 2009’s grand challenges can provide useful insights for planning 2010. Although issues were pervasive in many state sectors, their salience is being underscored in a few domains with a view to outlining possible policy directions that appear plausible for perusal.
By far the greatest challenge related to undermining of internal sovereignty in the settled areas of NWFP and the rapidly fading writ of the government in the Federally Administered Tribal Areas (FATA). Although a military operation appears to have quelled the insurgency in some parts for now, these areas still need to be brought fully under state control. In addition, the largest ever displacement of civilians needs to be rehabilitated and damaged infrastructure reconstructed. Inextricably linked to this is the growing trend of militancy and acts of terrorism across the country. Dealing with these systemic fault lines is the biggest challenge of 2010.
On the political front, although democracy has now prevailed for over 20 months, some key decisions relating to separation of powers, critical for democracy to function are still awaited. Ensuring a ‘democratic construct’ of the 18th Amendment to the constitution will be one of 2010’s grand challenges in addition to amendments relevant to provincial autonomy. Some progress with regard to the latter was evident in 2009 through the amicable decision on the National Finance Commission Award. The Balochistan Package — despite rejection by the Baloch nationalists — can also be a step in the right direction if there is a resolve to build further on it towards granting the provinces the needed autonomy while strengthening the foundations of Pakistan’s federal structure. This has now become an imperative as a counter to separatist movements, which are an additional evolving threat to internal sovereignty. Quantum leaps can be made in 2010 through a political solution to this long-standing question.
The economy faced many challenges in 2009 but did not, fortunately, experience the same disruptions as in the previous year. Pakistan’s entry into the IMF stabilisation programme and tightening of monetary policy, led to a positive impact on inflation and the IMF tranche helped in building reserves. Some level of fiscal discipline was ingrained, but at the cost of withdrawing subsidies. The grand challenge in 2010 would be to ingrain true fiscal discipline by narrowing the gap between revenues and expenditures. On the one hand this necessitates curtailing expenditures, stopping major bleeds from the fiscal system as in bearing the cost of running non-profitable public sector enterprise and rationalising the cost of running the civil government. On the other hand, this necessitates a move towards sustainable mechanisms of revenue generation. Although the government appears to be introducing the VAT with the latter in view, this indirect tax is not a substitute for widening the tax net and making the taxation system more effective. A challenge for 2010 would be to make substantive headway in the desired directions.
Fiscal constraints of the 2009/10 budget were in contrast to the expansionary fiscal policy as was evident in the largest ever Public Sector Development Program (PSDP). Ironically, this came after the largest ever cuts in PDSP the previous year on the premise that the gap will be filled with the envisaged forthcoming support from the Friends of Democratic Pakistan. To the best of knowledge in the public domain, pledges made have not fully realised. Forthcoming aid under the Kerry-Lugar legislation will not be a substitute for bridging this gap as most of it will be utilised off-budget. The challenge for 2010 would be to use aid to develop productive assets and build national capacity to mobilise domestic savings and raise domestic revenue so as to mitigate reliance on aid over the long term. However, a bigger challenge in 2010 in the economic realm would be to focus on the fundamentals of economic development and aim for growth and increase in employment rates. Here, many overarching issues, which stand in the way of investments and therefore realising this objective needs to be addressed: high interest rates and credit squeeze, both a fall-out of a tight monetary policy, poor law-and-order situation, public policy gaps, issues of governance, and crippling power shortages. These result in many impediments for businesses with resulting poor industrial growth, widening trade deficit and a negative spin on employment rates.
As social sector outcomes are determined more by overall socio-economic development than isolated changes within the sectors themselves, it came as no surprise that they remained intransigent in 2009. Although there is statistical controversy over prevalence of poverty in the country, it doesn’t appear to have declined in 2009. Additionally, major headway in human development could not be made despite pronouncements in the Poverty Reduction Strategy Paper II. In view of prevailing constraints, the government launched an income support programme to strengthen its safety net arrangements. There are of course improvements needed in this area, such as making the targeting system transparent. However, beyond income support, the grand challenge now would be to move towards holistic social policy reform, with planning relevant to the labour market, other areas of social protection, infrastructure and key services the government is meant to ensure the provision of. With reference to the latter, policy, legislative and institutional reform, which can ensure universal coverage by increasing public financing and expanding the base of service provision by harnessing the outreach of private providers must be pursued.
Good governance is the key to performance. However, tracking of six indicators, used for country assessments of governance, show major challenges in each domain. (i) With regard to voice and accountability, there was a mixed outcome in 2009. Although media freedom was positive, lack of desired progress on the new legal and institutional framework for accountability, unaddressed problems with the draft of the Holders of Public Offices Bill, inaction with respect to the freedom of information law, and prevailing uncertainty around the devolution initiative, which can ensure community participation in decision making, have been decidedly negative. Movement in all these domains of voice and accountability is a 2010 imperative; (ii) With regard to rule of law, while the performance of the superior judiciary has been widely hailed for its activist stance, concerns have also been raised about the institution side-stepping its mandate. This has particularly been the case with regard to the prerogatives of the executive in the decisions on the petroleum levy and setting of the price of sugar and in relation to the legislature in the recent decision which held that the NRO was void ab initito, notwithstanding the judiciary’s morally correct stance on that matter. Developing clarity in relation to prerogatives of state institutions would be a 2010 imperative; (iii) In the area of corruption, it suffices to say that it has continued to prevail: Transparency International’s report and media coverage bear testimony, which should make reform in this area a 2010 priority. (iv and v) the saga of the sugar crisis and other commodity shortages are a proxy indicator of government effectiveness and regulatory quality, which are two other indicators. Implicit in these phenomena is the capacity of vested interest groups, which threaten the impartiality of public policy decisions. Finally, the situation with regard to the sixth indicator — political stability and absence of violence/terrorism — has been abysmal, as is known to all. The grand challenges loop closes with an emphasis on the need to tackle this area, as success in any state domain is dependent on progress in this area.
The author is the founding-president of the NGO think-tank, Heartfile. Email: sania@heartfile.org
Beyond the NFC Award
Published in The News International on December 31, 2009:
The National Finance Commission (NFC) will be announced by the Prime Minister in Gawadar today. Felicitations are due not only for the amicable coming to fruition of a process fraught with long-drawn disputes, but also for the innovations which have been introduced with regard to a set of new criteria. Indeed, the dispensation of vertical and horizontal distributions from the divisible pool have ensured a better deal for the smaller provinces, and can pave the way for better federal-provincial and inter-provincial relationships.
Before some of the constraints that stand in the way of achieving these objectives are reviewed, the issue of resource transfers should be examined more closely. Systemic resource transfers are not confined to the NFC, but occur at three other levels — from the provincial to the local government; from the federal to the local government and from the local to another tier of the local government. There must be similar issues at these levels that are never brought to the fore, perhaps, since the local stakeholders do not wield the same influence as the provincial political hierarchy.
Additionally, there are random methods of resource transfers such as grants, which must be taken into account. This becomes important as the government is increasingly making use of debt swaps to free up resources, and in view of the envisaged inflow of aid under the new Kerry-Lugar arrangements. Although there will be no subventions and grants for provincial governments under the new NFC, given the 56 per cent provincial share from the divisible pool, a policy relating to random transfers will nevertheless bring greater clarity.
Now that the provinces are on their way to becoming more empowered, the question of other provincial taxes, which are to be levied and retained by the provinces such as the agriculture tax, should also be addressed squarely. There are political and capacity constraints in this regard. The extent to which the feudal dominated provincial assemblies will make headway in that direction remains to be seen.
An increase in financial resources for the provinces must bring to bear the poor correlation between total spending and intended outcomes, particularly development outcomes. Unless there are parallel efforts to improve returns on spending, not much will be achieved.
Several factors are known to impair the ability to expend; these include excessive centralisation of operational decision-making, onerous financial and administrative procedures, lack of accountability of decision-making delays, and limited capacity to plan and implement. An allied issue relates to quality of expenditures — tracking of budgetary fund flows in the public sector shows a predominance of expenditures in May and June before the financial year ends, with non-development budgets predominating. These constraints need to be addressed through financial management reforms.
In terms of returns on investments, the effect of corruption on compromising public investments in a highly-constrained environment must be taken into account. Leakage of funds from the system is an outcome of various forms of corruption. These occur because of poorly-managed expenditure systems and poor fiscal controls over flow of public resources.
Procurement graft is rampant and is fully institutionalised in many areas in provincial domains. It is, in fact, one of the ‘easiest’ ways of pilfering resources from the system. The recent attention to this systemic fault line should lend impetus to fully institutionalising procurement reforms.
In the same vein, it must be recognised that the there is an additional responsibility that the provinces now have with regard to generating surplus cash balance in order to meet budget deficit targets stipulated by the IMF, in view of the limitations that the federal government now faces, due to a decrease in the size of its share in the divisible pool.
Coming back to the NFC, the importance of building capacity to deal with the matter on an on-going basis must be concomitantly underscored. Although the decision on the NFC award has been remarkably well handled this time round, it is not a guarantee that it will always be the case in the future, which is why institutional capacity is needed to track progress and inform policy in order to guard against any future deviations as has been the case with NFC awards in the past. Inclusion of net hydel profits and royalties and excise duties on oil and gas in the divisible pool, which caused federal provincial tensions for years, despite the clear constitutional stipulation that these should be dealt with outside of the NFC award, is another example, while reflecting back in history. Yet another is that of implementation of the GST on services by the federal government, revenue from which under the constitution should have accrued entirely to the provincial governments. Although these matters are now history given that they have been admirably resolved under NFC 2009, they have nevertheless set a precedent in the past.
Then there is the long-standing issue of tax devolution, towards which the provinces would like to move and policy issues with regard to pros and cons of tax devolution that need to be balanced. All these and other complex issues need policy guidance on an on-going basis. By creating a dedicated intuitional resource for on-going policy guidance to strengthen fiscal federalism, NFC 2009 can have a sustainable impact on other awards in times to come.
The writer is the founder and president of the NGO think tank, Heartfile. Email: sania@heartfile.org
Road to anti-corruption reform
Published in The News International on December 19, 2009:
In a landmark decision on December 16, the Supreme Court has ruled on the legal validity of the National Reconciliation Order (NRO) and has termed it void ab initio for being ultra vires of the Constitution. In layman’s terms, the NRO stands null and void since its inception and all benefits acquired, accrued or incurred under it stand withdrawn. This decision is a very important cog in a chain, which is paving the way for strengthening the moral basis of anti-corruption reform in Pakistan. The sequence of events began with a series of Suo Moto actions by the Supreme Court, which played an important role in strengthening the societal political culture—a demonstration of which was part of the lawyers’ movement. Subsequently, the media’s drive to bring corruption as a leading public debate to the fore has also been commendable. The role of successive governments, which allowed a free media to thrive—reservations notwithstanding—should additionally be acknowledged. It appears that these events along with the realization that the need for clean and competent hands on the governments reigns are critical to alleviating the day-to-day crises facing the common man, can be key to lending impetus to holistic anti-corruption reform.
Why the emphasis on anti-corruption reform when the country suffers from so many crises—the question may be posed? The answer to this is embedded in some key realizations.
Corruption relevant to state governance has many shades—financial, ethical and procedural. Closely related to these are mal-governance, inefficiency and ineptitude, which in the absence of mechanisms to compel accountability can be equally damaging. Each of the problems that we see plaguing our nation today is a manifestation of one of these.
Over the years, we have seen the emergence of a form of governance where systemic manipulation was fast becoming well-ingrained; where state capture by vested interest groups and undue influence to shape state policies, laws and regulations, was becoming common place. In these environments, procurement graft was becoming institutionalized, preferential treatment and nepotism guided human resource decisions, and patronage and support for debt writing off, tax exemptions and other favours was fairly common. In general, decisions were usually not grounded in evidence and misuse of authority was fast gaining acceptance.
This style of governance steadily eroded the capacity of state institutions over time; it fostered public-private collusion and furthered vested economic interests of the powerful elite. There was massive diversion of state resources for personal gains and a growing trend towards cartel activity, which manifested itself in frequent commodity shortages of the kind witnessed over the last few years. These malpractices helped to further strengthen Pakistan’s growing informal and black economies, which thrived on smuggling, trafficking and a range of financial crimes.
As these practices got firmly ingrained, state resources got channeled to the well-connected through patronage and political links were furthered, establishing a vicious circle. Regulatory capture became pervasive and procedures were circumvented to settle police cases, change land documents, evade tax and get permissions and licenses. The ability of state institutions to target welfare was weakened. Moonlighting in the private sector and levying of charges for services that were meant to be provided by the state for free became common in the social sectors. The resulting outcomes were devastating—the rich-poor divide was augmented, the society become polarized and impoverished masses became exploitable in extremist hands. Upright politicians and state functionaries were weeded out of the system and reforms were held hostage. We were left with frail governance, weak political systems and a thriving informal economy.
All this may pleasantly be up for a change now! By upholding constitutional stipulations, the judiciary, and through its open confrontation of this menace, the media have lent impetus to a burgeoning transition. The two pillars of the state—judiciary and the media—have played their respective roles; it is now imperative that the two other pillars—legislature and the executive—also play their part in this transition. Anti-corruption measures necessitate deep-rooted systemic reform and it may not be possible to do everything at once. However, they are some critically important next steps, which need to follow.
The legislature must do five things: one, in the forthcoming 18th Amendment to the Constitution, it must aim for the right separation of powers and structure appropriate institutional checks and balances between the executive, judiciary and the legislature and ensure that constitutional restraints upon the elected government are in order. Second, it must revisit the freedom of information law—the oxygen of democracy—which has to do with access to information and disclosure, which can enable public discourse in larger national interest on issues of governance. Pakistan’s existing Freedom of Information Ordinance, 2002, which is still in force, has many weaknesses; some of these such as the excessive broad regime of exceptions and the restrictive approach to the definition of public record need to be addressed through appropriate amendments. Third, the Parliament must strengthen its Public Accounts Committee and empower it as an engine of oversight with active engagement with the civil society and expert groups. Fourth, it must revisit the Competition Commission law to enable the Commission to function independently as it is playing an important role in creating a level playing field for businesses and weakening economic interests that promote state capture. Finally, the legislature must finalize a legal and institutional accountability framework for the country. Weaknesses of the Holders of Public Offices Act 2009, in terms of the envisaged Accountability Commission’s prerogatives, the flexibilities and space for maneuverability, its structure in relation to purported independence, moreover the fragmented institutional design being structured under the bill’s aegis, has been the subject of great debate. These concerns need to be addressed in a new legal and institutional dispensation.
Finally, there is a set of imperatives for the third pillar of the state—the executive, or the government. Theoretically speaking, there are many things in that fold that need to be undertaken—revival of the National Anti-Corruption Strategy, strengthening of several institutions that have a role to play, mainstreaming technology to plug leakages, institutional changes in ministries that would separate policy making from regulation and implementation to reduce space for collusion, revival of the many donor-supported projects initialized by several governments, which can have a knock on effect on transparency, civil service reform, changes in public finance management, procurement reform and many other areas. It is accepted that it would not be possible for the executive to commence work on all of these areas at once. However, some strategic measures need to be taken to pave the way for broader reform and keep the momentum going. By doing just two things the executive can signal a strong commitment to change. One, upholding merit and creating incentives for integrity in public service at all levels—the cabinet and bureaucracy and two, assisting with needed reform in the judicial system itself.
The road to anti-corruption reform is long and winding but with the needed measures at the right time, progress is possible. As a nation we have long under-estimated and ignored the cost of corruption and mal-governance. We may be familiar with the staggering costs of commissions, revenue lost due to crony privatization, political patronage, tax evasion and the shadow economy but what we don’t recognize is the erosion of the social fabric and ethical and democratic values it has caused and the risks it poses to national security and peace. For now the judiciary has played a watershed role in what can be a burgeoning transition. Its coming to fruition will depend on how well the two other pillars of the state play their role to uphold accountability, transparency, professionalism and neutrality.
The author is the founding president of Heartfile. sania@heartfile.org
The federation and provincial autonomy
Published in The News International on December 12, 2009:
The Balochistan package, the implementation of which the Prime Minister envisages finalizing by December 15, has been received with views on both extremes of a spectrum. The ruling stakeholders term it as a significant milestone whereas the Baloch nationalists have rejected it outright.
From a review of the package it seems that the Parliamentary and Cabinet Committee mandated with the task of developing the package has carefully gone over the various bones of contention and has made an effort to make some allowances in the five-tiered package, without disturbing the current relationship between the federation and the federating units. Hence, some additional space has been created for Balochistan in the administrative, economic and political realms, with commitments to pay outstanding dues on account of royalties—a major concern in inter-provincial relationships—and an affirmation that the Parliamentary Committee on Constitutional Reform will review matters relating to provincial autonomy in the 18th Amendment.
If this package as its name suggests, is the beginning of careful strategic thinking and long term planning towards granting provinces the due share of autonomy, then it should be considered as the step in the positive direction. In isolation however, each of its components have their limitations, as the objective intended to be achieved through the Balochistan package is deeply interlinked with the issue of provincial autonomy and the relationship of the federation with its federating units. In this equation, the federal government’s mandate, the fate of the Concurrent List, discussions around the National Finance Commission (NFC) award, matters relating to provincial prerogatives with regard to sharing of resources and taxation and other prerogatives assume great importance. These must be addressed in a coordinated and step-wise manner.
First, autonomy must be defined in the context of fiscal and political federalism in Pakistan. Over the years, many calls have drawn attention to the subject, most of them subscribing to an extreme notion of autonomy analogous to what was envisaged in the 1940 resolution, which defined Pakistan as “a federation comprising of autonomous units, which shall be completely sovereign”. Views articulated in the Declaration of Autonomy of the Federating Units signed on August 2, 1986 by the leaders of the Movement for the Restoration of Democracy, also called for an extent of autonomy in which all, except four subjects—defence, foreign affairs, communications and currency—were to be delegated to the provinces. Many Baloch nationalists still subscribe to this view. The question is, do these four subjects guarantee a viable federation for Pakistan? What else is needed by way of the Federal Government’s mandate to fulfil the concept of a unified Pakistan and promote equity in development across provinces? Can the desired level of provincial autonomy be granted by implementing the five-point constitutional changes articulated in the Balochistan package, relating to abolishing the Concurrent List, the Local Government Ordinance 2001 and Police Order 2002 and effective implementation of Articles 153-160 of the constitution and by strictly adhering to the design of the federal-provincial relationship as stipulated in the 1973 Constitution, which as the Balochistan package acknowledges has been “circumvented” in the past? Or should we completely digress from the quantum of provincial autonomy as endorsed by the 1973 constitution? How can we achieve the dual goals of granting the people of Balochistan the right to self-rule and control whilst supporting national unity at the same time? These questions need careful thinking with a broad-based consensus on the directions to be pursued.
Second, the Federal Government’s mandate must be clearly defined. Many believe that the current federal system has been designed on the legacy of centralized control—a hallmark of the colonial period. In this arrangement, the federal government has been stretched thin with tasks that could better be taken in the provincial fold. Many also believe that there is a major disconnect between prerogatives to generate resources and expenditure responsibilities. It has been frequently cited that the Federal Government generates 93% of the resources and has 72% share in total expenditures; conversely, the provinces are left with 7% resources and account for 28% of the expenditure. Of the five expenditure heads of the federal government, the two that are of direct relevance to the question of provincial autonomy are the Public Sector Development Program (PSDP) and the cost of running the civil government. There are many subjects under the PSDP, which can better be assigned to the provinces. If there is a unanimous consensus to do so, the costs of running the civil establishment in Islamabad can be scaled down through structural institutional changes; the concurrent list can then correspondingly be pruned and the size of the National Finance Commission award for the provinces will therefore increase.
Third, the issue of the NFC Award is closely interlinked. Out of the seven NFCs since the 1973 constitution, only four have come up with additional measures. These—relating to the composition of the divisible pool, inclusion of taxes and revisiting the provincial share—although important in their own right, do not comprehensively address issues fundamental to fiscal autonomy of the provinces, which centre on taxation rights and mechanisms to assign permanent sources of revenue, particularly with regard to control over natural resources in line with what has been stipulated in Article 161.
Decision on the next NFC award is due later this week. Although there are inherent difficulties in balancing the varied demands of the provinces, there are ways in which provinces can be empowered to generate and retain their own revenue, whilst reducing concentration of revenue collection at the centre through major tax-heads, albeit without jeopardizing the core functions of the federation. In addition, sensible revenue collection criteria, which indicate economic activity in the province and hence revenue distribution can be devised and given weights in relation to criteria for distribution from the divisible pool. This can be supplemented by other criteria—indeed the provinces have a long term demand to include criteria other than the sole criterion of population as a basis of provincial allocations from the divisible pool.
Fourth, let’s not forget that the core purpose of provincial autonomy is to enhance public sector effectiveness. That in turn is closely linked to how the system of local governance will be shaped—an area in which there is pervasive uncertainty.
It is evident therefore that the issue meant to be addressed through the Balochistan Package needs a consensus-driven long term plan, which can be implemented in a coordinated stepwise manner. As this requires many institutional changes, immediate implementation of drastic and ad hoc measures should be avoided as it can lead to disenchantment in the administration particularly at the federal level, which can be detrimental at a time when the country is undergoing many different crises. But at the same time, the issue of provincial autonomy should not be taken lightly. In fact the determinants of the country’s split in 1971 were rooted in inattention to the subject. It is imperative to devise a long term solution acceptable to the provinces to ensure that the provinces have more space and control, whilst at the same time strengthening the foundations of the federal structure and inter-provincial harmony. However, in order to get things going in a coordinated fashion, long-term visionary thinking, strategic planning, and consistency of policy direction is needed over time. In tandem, careful and unbiased oversight has to be ensured so that capacity development and transparency-promoting reform is pursued in the provinces in parallel with granting of autonomy and responsibility. A “package” of measures, no matter how well-intentioned, has inherent limitations in achieving this long-term objective.
The author is the founding president of the NGO think-tank, Heartfile. E mail: sania@heartfile.org
Pakistan, Politics and Polio.
Nishtar S. Pakistan, Politics and Polio. Bull World Health Organ 2010. 10.2471/ BLT.09.066480
Amending the constitution
Published in The News International on November 28, 2009:
The Special Committee on Constitutional Reform, which was constituted to frame recommendations with regard to the construct of the 18th Amendment to the Constitution of Pakistan, is likely to come up with its recommendations soon. The focus of attention of the Committee and of the nation in general is on certain covenants of the Constitution—repeal of the 17th amendment in general and 58-2(b) in particular. Many political actors have also come up with specific recommendations with a focus on these and related issues.
An amendment to the constitution is not a trivial matter—whilst we await a debate on any envisaged recommendation, it is opportune to review the nature and history of constitutional amendments in the past, particularly with a view to exploring if they had any potential to strengthen state functioning and bring welfare to its people. These insights can be instructive in today’s environment as well.
Most of the amendments to the Constitution of Pakistan have been made in a fire-fighting mode. The principal objective of each—notwithstanding that constitutional amendments have also included other issues—has been centred on one of the three following areas. One, defining power relationships between the presidency and the prime minister’s office. The Constitution in 1973 provided for separation of powers between the president and the prime minister but greatly strengthened the position of the latter. The 8th Amendment in 1985, which validated the presidential order of 1977 and other marital law orders, albeit whilst curtailing some of the powers of a uniformed president, changed the form of government from a parliamentary to a semi-presidential system. The 13th and 14th Amendments weakened institutional checks on the prime minister’s powers. The 17thAmmendment, which revived the constitution in 2002 and validated all the constitutional amendments promulgated under LFO no 24 of 2002, restored 58-2(b), and therefore, presidential powers. The current debate on constitutional amendments centred on 58-2(b), is aimed precisely at removing these and empowering the prime minister.
The second issue, which constitutional amendments have been centred around relates to enhancing or curtailing powers of the judiciary and the political parties. Of the 13 amendments—out of a total of 17 that were tabled—the first seven, passed in May 74, September 74, February 75, November 75, September 76, December 76, and May 77, respectively, were focused on the prerogatives of political parties and the judiciary.
The third issue considered germane by many in the country to constitutional amendments is the role of Islam in state functioning. The second amendment to the constitution pronounced Qadianies non-Muslims. The 9th Amendment Bill and the 15th Amendment Bill, both concerning enforcement of the Shariat, could not be enacted.
Here it must also be recognized that a few amendments, other than in these three areas have also brought some value to the state system. For example under the 12th amendment the salaries and remuneration packages of the judiciary were revised and under the 17th amendment, women’s representation in the parliament was increased, minorities were given the right to vote, the supreme judicial council was given the authorization to file a reference against a judge, the right to dissent was granted and some other areas, which relate to political representation were also addressed.
These notwithstanding, by and large, constitutional amendments have been about the three issues that have already been alluded to. This brings us to the question of whether this should be the case? Stalwarts in the area should know the answer.
A constitution is the most basic law of a territory from which all other laws and rules should be derived. It is true that constitutions are, in a sense, living documents and need to be revised form time to time based on emerging needs. However, amendments need to be focused holistically on all the core objectives that the constitution is meant to achieve. Constitutions serve many important functions. Regulating the relationship between institutions of the state and the relationship between the executive, judiciary and the legislature and the relationship of institutions within these branches is one. This is an area, which has received the most attention, but the focus has been highly narrow and has remained individual-centric.
Two, the other most important function is to define the relationship between individuals and the state and third, to establish the broad rights of individual citizens. There has been almost no attention to these areas in successive constitutional amendments in Pakistan.
A review of constitutional amendments in other countries reveals that these have focused on diverse subjects of public interest such as civil liberties, rights, rights to privacy, citizens’ privileges, immunities, due processes, etc. In Pakistan there is no such trend. The societal political culture being weak, there is also no pressing public demand.
Even the Principles of Policy, which are a set of values that guide action towards desired goals, have not been updated since the original framing of the Constitution in 1973. The world has changed significantly since then and therefore the need for new normative frameworks. The writer has attempted to draw attention to the 8 missing Principles of Policy and has recommended modification to two existing Principles in these columns on September 19, this year, in line with this understanding.
Similarly, the question of rights needs a concerted focus. Under the Constitution of Pakistan, most of the fundamental rights listed in Chapter 1, Part II—entitled Fundamental Rights—fall within the domain of civil and political rights. Socio-economic rights have not been explicitly recognized as rights in this chapter. However, a reference to socio-economic ‘rights’ features in two areas in the constitution. The Objectives Resolution, which forms the preamble to the constitution and was originally passed in 1946, makes an explicit reference to social justice as one of the five principles guiding the democratic state. Secondly, Article 25 and 38-d of chapter 2, Part II—entitled Principles of Policy—refers to ‘Equality of citizens’ and ‘Promotion of social and economic well-being of the people’, respectively. Other articles of relevance include Article 9 on ‘Security of a person’ and Article 14 on ‘Inviolability of the dignity of man.’ Conventionally, these covenants are referred to as being the basis of socio-economic rights, with Article 8 and 9 read with Article 199 providing the basis of enforcement of fundamental rights. Article 9, in particular, has been broadly interpreted in case law in this regard. However, socio-economic rights have not been explicitly recognized as fundamental rights. Every time a constitutional amendment bill was tabled, the opportunity to holistically review the matter of rights was missed.
Even in the area of civil and political rights, there is lack of clarity in relation to freedom of information, which is an important component of the international guarantee of freedom of expression. The Pakistani constitution does not refer to the right to seek and receive information as elements of freedom of expression, as outlined presently in Article 19. However, despite this lack of clarity, the Supreme Court, in a 1993 ruling, stipulated that the right to freedom of expression includes the right to receive information, as discussed in these columns on October 12, 2009.
The word limit precludes a discussion on other areas, such as administration of the tribal areas and the subject of provincial autonomy, where amendments are also desired. The need to revisit the Concurrent list and the federal fiscal system has been raised time and again; in fact, the sixteenth amendment bill—a private members bill—was tabled on the subject of provincial autonomy but it couldn’t pass.
It is therefore an imperative that once the existing constitutional fire fighting is over, attention should be focused on other constitutional areas, which have remained orphaned in terms of the attention received.
The author is the founding president of Heartfile. E mail sania@heartfile.org
The way forward—post NRO
Published in The News International on November 07, 2009:
The emotional turmoil, which the nation was going through over the fate of ethical standards in accountability norms and the threat of the widening gulf between justice and law appear to be easing with indications and pronouncements by the government that it will not seek validation of the National Reconciliation Ordinance (NRO) through the Parliament. With this decision, the NRO will stand repealed on the expiry of a period of four months from July 31, 2009—the date of the short order of the Supreme Court in which the November 3, 2007 Proclamation of Emergency and related PCO was declared void ab initio. The decision will be a positive step indeed and can help in fostering a positive environment for the establishment of an accountability framework within the country. It must be recognized however, that although necessary, this is not a sufficient step to overcome the myriad of challenges that stand in the way of developing a legal, policy, and institutional framework for mainstreaming accountability in governance within the country.
Before these challenges and the opportunities arising as a result thereof are discussed, two things about the NRO must be appreciated. First, the decision of the parliament is, in a way, irrelevant with respect to the individuals who were eligible to derive benefit from the NRO, as benefits acquired, accrued, or incurred under the NRO during the first four months of is validity have already been derived. Repeal of a law does not, according to the Constitution’s Article 264 “affect any right, privilege, obligation or liability acquired, accrued or incurred under the law.” Secondly, it is also apparent that by not declaring “the NRO void ab initio for being ultra vires of the Constitution,” as explained by a legal expert in these columns on October 26, and by referring the matter to the parliament, the Supreme Court—the two pending petitions notwithstanding—has refrained from ruling on the legal validity of the Ordinance. If the Supreme Court had held that the law was invalid the outcomes would have been different altogether. What’s done is done. It is time to chart the way forward now.
In the aftermath of the NRO, therefore, it is critical that we look beyond the highly charged personalized discussions to draw lessons from a systemic controversy and use insights to develop an accountability framework—one in which safeguards are built against the chances of exploitation and manoeuvrability in the future. This is also an opportune time to do so. The accountability statute is currently under review by the Parliamentary Committee on Law and Justice. Although the government has not heeded to its earlier recommendations, which called for making the statute more robust, a case can still be made for modifying the Bill.
The new Bill entitled Holders of Public Offices Act 2009 (HOPA or Bill) would, if enacted, repeal the National Accountability Ordinance (NAO) and replace the National Accountability Bureau (NAB) with an Accountability Commission (AC).
It is critical that we take stock of the weaknesses of the envisaged legal and institutional framework to be established under the HOPA. In this regard a careful analysis of the characteristics of the NRO beneficiaries, the pattern and specifics of cases that were withdrawn, and the nature of penalties bypassed can be instructive as the new law must bring these within its purview. A review of covenants in the Bill conversely indicates that this hasn’t been the case so far.
A range of public functionaries and members of private financial institutions and not just holders of political office benefited from the NRO. But paradoxically the definition of “holder of public office” in the Bill has been restricted to holders of political office. For the latter category the definition of corruption has been made more restrictive by excluding “owning unaccounted for property disproportionate to ones means, misuse of authority, and the granting of concessions for one’s own benefit.” Whilst it is recognized that these areas can be easily exploited for political victimization, it is also precisely in these areas where corruption and misuse of public office becomes most pervasive.
The prerogatives of the new AC are also being curtailed in the same vein. The new AC will have limited investigative powers with a limitation period upon prosecution as opposed to NAB, which is more comprehensively empowered as an investigative and prosecutorial agency. Limitations imposed on the AC relate in particular to its powers to seek information during an investigation both in Pakistan and abroad, its powers to freeze and seize assets during investigations and its powers to arrest. Penalties have also been reduced—the disqualification period in relation to public office has been reduced from 21 years to 5 years and an avenue is being created for those that return misappropriated assets, as they will deem automatically acquitted under the new law. HOPA also absolves banks of their responsibility to report suspicious transactions. There are inherent difficulties with regard to conviction for graft, given that corruption does not leave a paper trail. With limited scope, restricted prerogatives and milder penalties under the new framework, it will be even more difficult to do so in the future.
Rather than using the NRO insights to strengthen the accountability framework it appears that flexibilities are being introduced into the legal framework. The natural assumption is that this is being done to facilitate collusive behaviour. However there may also be other reasons. For one, the long term negative impact of the legal framework on accountability, as a governance norm may not be fully appreciated. If that is the case, the importance of analyses being offered on the subject must be heeded to in all earnest. The other reason could relate to the fear of political victimization. After all, most instruments and institutions of accountability, which could offer potential, have been sacrificed at the altar of personal vendettas and political exploitation in the past. The many criticisms targeted at NAB, for instance, were not a result of inherent structural weaknesses in the design of the institution that couldn’t be remedied, but due to systematic manoeuvring for achieving political objectives. The answer to this problem is not in cutting back on prerogatives, but in structuring impartial oversight, independence in governance and openness in disclosure with reference to the AC. Unfortunately, the AC’s current design doesn’t draw on the strengths of these attributes.
The prerogatives of the chairman are illustrative in this regard. Under the new AC, an inquiry can only proceed with a go-ahead with the chairman and/or his designate—clearly a few individuals can fall prey to capture by Pakistan elite-dominated political dispensation. The opportunity to foster participatory governance has been missed in the new statue and needs to mainstream.
The Bill in its present form, will not only restrict the scope and remit of accountability, it will also alter its current institutional configuration. NAB represented the model of a single multi-purpose ‘independent’ agency. A model which has proved to be successful in many Asian countries where the attributes of governance referred to earlier have cascaded in institutional designs. In the model of accountability governance being instituted through HOPA, accountability and responsibility for corruption will be assigned to various agencies—FIA, police, AC and session courts and criminal laws set out in the PPC will serve as the legal framework for cases of corruption, which fall outside of the jurisdiction of HOPA. Clearly, reform of a single agency is a lot more feasible than systemic changes in many crumbling institutions.
Accountability as a core attribute of governance is dependent critically on the governance of an accountability framework! We must not loose the opportunity to structure that in a robust design.
The author is the founding present of the NGO think tank, Heartfile. E mail sania@heartfile.org
Public stewardship of mixed health systems.
Lagomarsino G, de Ferranti D, Pablos-Mendez A, Nachuk S, Nishtar S, Wibulpolprasert S. Public stewardship of mixed health systems. Lancet 2009 Nov 7;374(9701): 1577-8
Is it feasible to merge ministries?
Published in The News International on October 31, 2009:
Aid conditionality appears to be a subject of recent controversy—not all conditionalities are controversial though. Some—as pointed out by the writer in these columns on October 22—particularly those related to governance reform may be useful for a country, if the structural changes stipulated are carefully implemented. However, in doing so the country must have the capacity to analyze how the generic approaches embodied within aid instruments can be germane to strengthening a specific aspect of governance or management within a country context. This comment focuses on one of International Monetary Fund’s several recent conditionalities to highlight how that can be the case.
In its recent set of conditionalities, the International Monetary Fund has stipulated that the government abolishes 13 ministries with a view to reducing unnecessary establishment expenditures. The suggested approach can be important within the context of the current fiscal space constraints in view of the country’s prevailing macroeconomic situation and the need to rationalize costs, better integrate programs, and reduce duplication within that milieu. In addition, it is also additionally relevant to the ongoing negotiations on the National Finance Commission (NFC) Award and the deliberations currently underway, with regard to constitutional amendments and the fate of the Concurrent List. In relation to the NFC award, provincial concerns about the federal government taking a large pie of the federal divisible pool and calls on their part to adopt measures to reduce the cost of running the civil bureaucracy in Islamabad is one reason why merger of ministries should be considered as an option. Ideally, this should be part of a larger drive towards greater provincial autonomy, scale down/abolition of the concurrent list—an outcome, which the Parliamentary Committee on Constitutional Reform should be headed towards. But even if that were to happen, merger of ministries and duplicating structures—theoretically, an evidence-based approach—would be an extremely difficult measure to implement, because of turf issues and jurisdictional, structural and other human resource-related considerations. Some of these issues may be unique to each one of the 13 ministries, where merger is proposed. Merger of the Ministry of Population Welfare with the Ministry of Health would, in fact, present the highest level of complexity for a number of reasons, which are briefly alluded to here to highlight the magnitude of the envisaged challenges.
Prima facie, it appears logical to merge the federal and provincial structures of the health and population sectors. Both have ministries at the federal level and provincial departments; both have similar administrative units and service outlets in the field and mobile service units. However, despite this similarity, functioning of both the sectors is quite different. Both the sectors have different sources of funding and different channels of fund flows and controls. The population sector is financed entirely through federal funds from the Ministry of Population Welfare down to its service outlets in the districts. Flow of funds takes place through special channels different from the normal channels of the provinces and districts. Health, on the other hand, is funded by federal funds at the federal level, by provincial funds at the provincial level and by allocated provincial funds at the district level; local funds are also allocated at the district level. Unlike population, resource allocations in health at the provincial and district levels are independent of directives from the Ministry of Health. The funding mechanisms for health and population, therefore, follow separate channels with different arrangements. Hierarchical relationships within each sector are also different—population is federally funded, is not devolved and is only partially de-federalized, whereas health is both federally and provincially funded and stands decentralized. As a result, there is hierarchical continuity in population—from the Ministry of Population Welfare to Population Welfare Departments to districts in planning, programme formulation and implementation and monitoring. In the health sector, there is no such continuity. The departments of health make their own programmes without directions from the Ministry of Health, and similarly, the district governments are free to determine their own priorities without any reference to provincial priorities even if they exist. Both these complicated standalone arrangements can be an impediment to any efforts aimed at institutional merger.
A historical review of efforts aimed at merger and functional integration also indicate reluctance on part of both population as well as health. Merger poses a threat to the careers of staff in the Ministry of Population Welfare, who are likely to resist if status quo is challenged. On the other hand, reluctance on part of provincial health departments is also evident. Despite several high-level directives over the last three decades, significant progress has not been achieved. These directives include the Executive Committee of the National Economic Council’s (ECNEC) decision of 1985, the Federal Cabinet decision of 1991, the Chief Executive Review Committee’s recommendations of 2001, and the decision of 2006 by the National Commission for Population Welfare, which was presided over by the then Prime Minister. In addition to lack of will at the administrative level, there also appears limited political will to go ahead with mergers, as this would eliminate an additional slot for a minister—something political governments vie to create in order to oblige functionaries. Constitutional stipulations pose additional difficulties. Health is a provincial subject whereas population is in the Concurrent List. As a result of all these considerations, merger can be fraught with many impediments.
Lessons from other developing countries can be instructive in assessing the impact of institutional impediments on any attempt that aims to merge institutional structures. The example of Bangladesh is particularly relevant for Pakistan, given the institutional similarities. Bangladesh experienced difficulties in merging its health and population departments even though it had more favourable conditions compared to Pakistan—unitary form of government and therefore no provincial level, continuous and identical hierarchical structures, same funding sources and similar channels of fund flows and no difference between the two hierarchies with respect to the degree of decentralization. This experience can provide useful insights into the dynamics of institutional integration vis-à-vis the countervailing forces and their determinants.
Despite these challenges, it must be recognized that merger is not just a valid approach from a fiscal and efficiency standpoint it is also a technical imperative. Health and population have shared agendas, which calls for integrating family planning with healthcare. As both the sectors need to be reformed in their own right given their abysmal operational performance, it makes sense to merge both the institutional hierarchies in any new arrangement. A recent policy analysis on the subject published in a special supplement of the Journal of Pakistan Medical Association has called for reconstituting service delivery arrangements, where family planning and reproductive health can be grouped together in the package of essential health services. The latter needs to be benchmarked as a yardstick for public delivery and as the basis of contractual relationships in new management restructuring arrangements.
The analysis notes that although merger is not the only solution to the multifaceted issues faced by the health and population sectors—both being influenced by the social and economic determinants and overall performance of state service delivery systems—it is nevertheless necessary if not a sufficient step. Examples of successful institutional mergers in the corporate sector reaffirm the notion that if the right incentives can be created for human resource, institutional mergers can actually be achieved.
The above-mentioned case demonstrates the complexity involved in institutional mergers. These complexities also hold true for any structural decision. The ultimate success of structural changes rests on the capacity of a country to analyze the imperatives, the envisaged impact and possible fall-out of decisions and its commitment to deploy knowledge-based solutions. We must enhance our capacity in these areas.
The author is the founding president of Heartfile. sania@heartfile.org
Aid empirics
Published in The News International on October 22, 2009:
The recent discussions regarding the Kerry Lugar Bill and the debate about the value of aid in general on its sidelines, brings to the fore the understanding that both sides—donors as well as Pakistan—have very high expectations of aid in terms of what it can deliver and catalyze. Before setting such high hopes, it is critical that we impartially analyze the past impact of aid on various outcomes in Pakistan. Whilst doing so, it is important that we move beyond polarized and politicized discussions on the subject; balance sensitivities with pragmatism; get a common understanding of the evidence that can guide future action; and carefully plan so that the interest of Pakistan as well as the global community can converge.
Before flagging the analytical dilemmas, a key prerequisite is to get the bearings right. The aid ‘industry’ is complicated. A number of actors—multilateral and bilateral development agencies, the United Nations system, global health initiatives, and private foundations are part of its landscape. Aid is delivered as grants, concessional loans, debt swaps, and bail out packages through various instruments under different policy and contractual norms. In Pakistan, it is a conglomeration of humanitarian assistance; military assistance, in-kind aid, particularly in the case of food aid; budget support; and Official Development Assistance—the commonly used measure of development aid. In case of the government, support is on-budget and off budget and on-Public Sector Development Program (PSDP) and off-PSDP. There are projects of various cycles with information relevant to allocation, disbursement and expenditure, which need to be taken into account. Before analyzing impact, it is important to ascertain if information is in order to allow analysis. The Donor Assistance Database of the Economic Affairs Division needs to be reviewed in this regard and other sources of information identified to allow triangulations.
Many questions emerge with regard to the actual impact of aid. The first is overarching in nature. Pakistan’s history of aid is closely related to its role as an ally in international politics during the ‘three decades’ of surges in international aid—1960s, 1980s and 2001 onwards—during which donors envisaged support to lead to a set of outcomes. Outcomes, of course, mean very different things depending on which side of the fence you are on. Pakistan was successful in enabling the donors to meet their foreign policy objectives in these decades. But how strongly did the decision makers of the time think of how to exercise leverage on the support provided to Pakistan to strengthen process of the state and bring welfare to its people. Did the conflicting polices pursued in concert with the latter two ‘cycles of support’ inadvertently pave the way for the current conflict. We must delve into these determinants, and learn lessons. The purpose is certainly not to discredit aid during these years, as aid also brought significant value, but to use strategic insights to shape policy.
Secondly, the impact of aid on macro-economic outcomes needs to be ascertained. Aid has led to growth in the ‘three decades’, but growth couldn’t be sustained. Expert economists can help ascertain why that was the case and determine the impact of aid on other macroeconomic outcome-related parameters. Was aid able to bring about improvements in productive assets and did it go preferentially into projects that could generate resources necessary to pay back loans? To what extent did aid build national capacity to mobilize domestic savings and raise domestic revenue? Is there any correlation between aid and domestic savings and between aid and the tax-GDP ratio? Were grants ever used to repay debts? What exactly has the impact of grants been on contributing to dependency? And how predictable has aid been? The government should conduct and consolidate an empirical analysis in order to draw on objective insights, which should then be used to shape policy.
In the third place, the potential within aid vis-à-vis other resource mobilization options needs to be objectively ascertained. Aid is perceived today as the option of choice, despite the understanding that widening the tax net is a more sustainable option. It is generally stated that the latter cannot be achieved because of state capture by the elite, in particular feudal landlords and interest groups, which are currently outside of the tax net. It needs to be ascertained if that is the case and if the links created through political patronage can further such collusive behavior. The institutional capacity constraints at the level of governance, which limit the ability of the government to access financial markets and/or mobilize funds through innovative means are also particularly important in this regard and need to be determined. It takes a lot more than aid to improve macroeconomic and development outcomes—a consideration the writer has recently alluded to in these columns on September 28. In the same comment, the potential within external resource transfers/support other than aid has also been underscored—in particular with reference to debt relief, foreign remittances, terms of trade and intellectual property.
In the fourth place, the impact of aid on social outcomes must be assessed. Was there any increase in aggregate allocations for the social sectors during the ‘three cycles;’ did utilization improve; was there any impact of aid on plugging pilferages and leakages from the system? What has the effect of aid been on outcome indicators? Can improvements be attributed to the inflow of aid? And if that has not been the case, were the central systemic issues that impeded the impact of aid on outcomes, included as targets in subsequent rounds of aid indicators?
Donors have invested in a number of projects over the years. Were these grounded in practical pragmatic realities? What percentage of them could be up-scaled and how many had a knock on effect on broader systems restructuring. Was there any accountability of public functionaries for not taking recommendations of technical assistance reports—many of which were funded through loans—to fruition? These areas are difficult areas of policy research, but are nevertheless very important to get a sense of before renewing the expectations of what aid can achieve.
In the fifth place, assessing the impact of conditionality on performance and ownership becomes critical, particularly in view of the recent divide of opinion over the Kerry Lugar conditionalities. Pakistan has complied with a number of aid-related conditionalities in the past. IMF’s stipulations in order to overcome external payment problems, structural adjustments, privatization of state enterprise, changes in policy norms and legislative arrangements are all examples of conditionalities that Pakistan has complied with in the past. The impact of these conditionalities should be assessed. The Paris Declaration on aid effectiveness indicates that conditionalities can undermine country ownership—in case of the Kerry Lugar Bill that does appear to be the case. However, on the other hand some conditionalities, particularly those that relate to transparency building reform of governance can be useful in the long term if the fundamental structural reforms stipulated as part of these polices are faithfully implemented.
Lastly, we must explore if there were any negative inadvertent consequences of aid. Is there evidence of aid having crowded out the space for domestic investments, particularly in the social sectors? And if that was the case, was it due to issues with utilization or the fear of long term unpredictability of aid. Evidence from some countries demonstrate that governments might use international aid to keep their foreign exchange reserves stable and spend the local currency counterpart with resulting macroeconomic problems, such as inflation. The potential impact of this phenomenon in today’s complex environment must be taken into account.
Aid can be an important catalyst. However, its impact is directly related to the robustness of the local system of governance. Evidence-guided planning is needed for addressing the challenges in making aid effective. In order for that to happen we must seek answers to these questions.
The author is the founder president of Heartfile. E-mail: sania@heartfile.org
Freedom of information—oxygen of democracy
Published in The News International on October 12, 2009:
A number of civil society organisations have drawn attention to the need for strengthening Pakistan’s existing Freedom of Information (FOI) legislative framework on September 28 —the Right to Know Day. FOI is not to be confused with media freedom. FOI is an important component of the international guarantee of freedom of expression, which includes the right to seek and receive as well as impart information and ideas. It has to do with access to information and disclosure, which can enable public discourse in larger national interest on issues of governance. FOI has been described as the ‘oxygen of democracy’ by Article 19, the Global Campaign for Free Expression.
Within this context, this comment is aimed at exploring the current instruments and the approaches that can be adopted to strengthen the FOI-related normative framework in the country. The issue has assumed importance in Pakistan for a number of reasons. First, the opportunity to review constitutional covenants with respect to the said subject must not be missed in view of the on-going debate on constitutional amendments. Secondly, there appears to be a renewed interest in Pakistan’s existing Freedom of Information Ordinance, 2002, which despite its weaknesses is still in force. In fact, the incumbent government had signaled its intent to repeal the law and re-enact legislation in this area on assuming office a year ago. The third imperative stems from the openness of the electronic media and heightened interest of the literate population of Pakistan in current affairs, and the recent burgeoning of disclosures – the motivation behind some of which are a point of great debate today. Lastly, the access to information clauses in the Kerry-Lugar Bill also create an imperative for the government to strengthen its own normative framework.
The Constitution of Pakistan does not refer to the right to seek and receive information as elements of freedom of expression. Article 19 states that “every citizen will have the right to freedom of speech and expression”. Freedom of information is not explicitly included in the guarantee of freedom of expression, which includes the right to seek and receive as well as to impart information and ideas. Pakistan has also neither signed nor ratified the United Nations’ International Covenant on Civil and Political Rights. However, despite this lack of clarity, the Supreme Court in a 1993 ruling stipulated that the right to freedom of expression includes the right to receive information. Here, it must also be noted that the Universal Declaration of Human Rights (UDHR), in its Article 19, which guarantees the right to information — though not binding on states — is widely recognised as having acquired legal force in customary international law, since its adoption in 1948. The current constitutional amendments, therefore, need to clarify if FOI is an explicit civil right in Pakistan.
It must also be noted that it is purely coincidental that Article 19 of Pakistan’s Constitution and Article 19 of the UDHR focus on the same subject. Article 19 is also incidentally the name of the Global Campaign for Free Expression, an international NGO which conducted an in-depth analysis of the 2002 Ordinance, as has been described later in this comment.
Pakistan was the first country in South Asia to promulgate a FOI law. Two laws have been promulgated, to date — both as presidential ordinances. The FOI in 1997 lapsed, as it could not be re-promulgated whereas the 2002 Ordinance, which was promulgated to comply with an Asian Development Bank conditionality, acquired permanent status after the 17th Amendment. This federal statute was followed by similar legislation in Sindh and Balochistan.
Article 19, the Global Campaign for Free Expression, issued a memorandum to articulate its views over the 2002 Ordinance the same year. A number of positive features of the ordinance were highlighted. Among these were “inclusion of the interpretation clause, the right to appeal to the ombudsman, a clear time frame for release of information and the inclusion of courts and tribunals in the definition of public office.” The memorandum also alluded to many weaknesses of the 2002 ordinance. In particular, the excessive broad regime of exceptions and the restrictive approach to the definition of public record.
Several sections of the 2002 ordinance in particular exclude many categories of public documentation from the purview of this law. The lists of exemptions in the 2002 Ordinance are broad and seem to implicitly extend to information that is proprietary, intellectual property right or trade secret-related; information of a personal nature; personal health and employment-related information, and information relating to procurement processes that involves pre-qualification information. The list also includes classified information where disclosure would undermine protection of public interest as regards public security, defense, and military matters; international relations; and financial, monetary, or economic policy. These exceptions when truly exercised are justified.
The issue relates to the exemption list in the area of information that is termed ‘privileged internal’ or ‘other information’. As part of this many internal notes, memoranda, and deliberations on state policies and laws are precluded from being in the public domain. Deliberations of the ECC or the cabinet, for example, are not in the public domain and when they are declassified, the time window to make meaningful use of the information is already lost. Even if these concerns are addressed, the utility of any FOI law remains questionable in Pakistan since many laws can still be invoked at any time to override the statute. Various sections of the penal code and a number of laws of contempt, official secrets, and censorship are notable in this regard and make the existing FOI statute, in effect, toothless. It needs to be explored if protection and immunities can be built into the new iteration of the FOI law to guard against this.
As the law has to operate in the broader context of governance, review of transparency promoting laws, particularly in the area of whistle blower protection, and accountability assume importance, as these can be supportive to promoting a culture of freedom of information. The analysis presented in the memorandum also brings to attention the absence of a provision to strengthen the public’s right to know and the lack of a clear obligation on training authorities to train public sector functionaries in this regard.
The most important aspect of developing and implementing an FOI legislative framework is to change the institutional culture within government agencies and the civil society. Governments inherently mistrust the civil society and perceive FOI as a tool that meddlesome NGOs and individuals use for harassing public functionaries. Some NGO and individuals, on the other hand, also have very complex motives and tend to abuse the ‘right to know’ prerogative. On the other hand, public functionaries often unduly guard information that can be put to constructive analysis by impartial civil society actors, benefiting the government in turn.
The government needs to fully appreciate that the public has a legitimate interest in being kept informed in a democratic society. The civil society must also be cognizant of the fact that governments have a legitimate interest in withholding information in certain circumstances.
In order to fully realise the potential within FOI as an essential underpinning of participatory democracy, good governance and accountability, both sides must exercise this right with great prudence and responsibility. However, it must be recognised that FOI is not an end in itself, but a means of improving governance. In that respect, it is just part of a holistic approach that needs to be fully institutionalised.
The writer is the founding president, Heartfile. Email: sania@heartfile.org
Is aid the answer?
Published in The News International on September 28, 2009:
The meeting of Friends of Democratic Pakistan (FoDP), convened on the sidelines of the United Nations General Assembly in New York, concluded yesterday by signaling unprecedented support to Pakistan. This was evidenced in both the representation at the meeting as well as in the approval announcement of the Kerry Lugar Bill, which is aimed at facilitating economic, security and socio-economic assistance. This comment with its focus on the development perspective is centered on exploring if aid is the answer to the current development challenges, the country faces. The importance of three points is being underscored in this regard.
First of all, it must be recognized that the best way to improve development outcomes is through sustaining growth, increasing employment rate and per capita income and by addressing the core disparities of power, money and resources. This notwithstanding, it is generally accepted that if aid is used as a strategic input into a system and if the central systemic barriers, which continue to impede its greater impact are addressed, it can be a useful tool and can catalyze development in a developing country setting. Based on this premise and research results, it is justified to argue for increased aid. However, expectations about its impact must be kept at reasonable levels in a country as large as Pakistan where aid is often grafted on local institutions without strengthening them from within. Experiences from around the world show that ‘more resources’ do not automatically translate into ‘more development’. If that was the case, Nigeria and Angola would be advanced countries based on oil resources alone, and would not rank 154th and 157th out of 179 countries on the Human Development Index. Clearly, the effectiveness of aid is dependent on some specific characteristics of a country—the critical link being the effectiveness of governance.
Secondly, even if we imagine that development depended critically on external resource transfers, there are many sources besides aid, which should additionally be leveraged. Friends could forgive more debt and could even go as far as wiping out external indebtedness, as they have done for some countries in Africa. They could give Pakistan better market access, a point being repeatedly made by Finance Minister Tarin these days. Friends must also carefully explore the amount of tariffs they collect vis-à-vis the money they provide in aid and facilitate trade by dismantling the barriers to exports from Pakistan, if they want a sustained effect of the good will they have signaled yesterday.
They could also facilitate ethical ‘export’ of human resource on the premise that the approach can enable earning foreign remittances, albeit whilst concomitantly building country capacity to implement appropriate retention regulation to ensure that the critically needed workforce is retained in the country. They could also help widen the definition of public goods by easing some of the impediments that are inadvertently placed on development such as through Intellectual Property Rights, particularly in the domain of medical products and technological solutions. Pakistan will have to be fully compliant with the patent regime under the stipulations of World Trade Organization Agreements and Pakistan’s Patent Ordinance, in 2016, which is when these considerations will assume importance. Furthermore, as Pakistan is envisaged to face the most deleterious consequences of global warming given the storage capacity of glaciers and monsoon patterns, Friends can also help by building capacity for responsible environmental management. Most importantly, strategic technical inputs, subsidies, diplomatic and market interventions in many other areas can ensure energy, food and water security—all of them critically needed as the backbone of development.
Thirdly, much can be done within the purview of traditional bilateral and multilateral Official Development Assistance (ODA) to enhance effectiveness. As a starting point, clarity of objectives is critical. A historical review of ODA in Pakistan shows that integration of foreign policy and development objectives has not yielded far-reaching development dividends in Pakistan, so far. There has traditionally been a very strong correlation between geo-political motivations and the volume of ODA channeled into Pakistan. The increase in ODA in the decade of 1954/64 in concert with Pakistan’s signing of mutual defense assistance agreements with the US in the Cold War era; in the 80’s in the wake of the Afghan war; post 9/11 for obvious reasons and the troughs in the pattern of aggregate allocations in the periods in between, are illustrative in this regard. Donors must therefore clearly separate objectives and develop broad-based channels of communication so that they can benefit from impartial inputs from a broad constituency of stake holders, and analyze the implications of integrating foreign policy and development objectives in Pakistan’s complex body politic.
The mode of channeling of resources is another consideration. Over the years, donors have rallied around a number of approaches to disbursement, each with its own set of problems. Experiences with Project assistance and Sector Wise Approaches led to intra and inter-sectoral imbalances. Programme assistance was introduced as a way of mitigating these challenges. It was envisaged that by agreeing on a set of criteria with the government and reimbursing them according to a predetermined percentage, as in the case of the Social Action Program (SAP), earlier problems could be mitigated. SAP dominated donor disbursement strategies from 1992-96 but without the impact envisaged. More recently, the tendency to give aid on budget is the third disbursement channel—an approach endorsed by the Paris Declaration and Accra Agenda. Many bilateral development agencies operating in Pakistan have made increasing use of this disbursement channel, on the understanding that coordinating and pooling aid in support of strategies led by the government, can strengthen country systems and minimize duplication and high transaction costs. However, systemic weaknesses have prevented the government from fully benefiting from ODA inputs, whilst also precluding realization of donor development objectives. Donors are experimenting with yet another approach to disbursement in the new package of assistance, as evidenced in yesterday’s announcement through the creation of a multi-donor trust fund. The approach has the potential to be useful if the fund parameters include a truly impartial, inclusive, and participatory governance arrangement, open disclosure policies and third party audit.
There are other things that both sides can do to improve aid effectiveness. The Pakistani government should strengthen fiduciary systems and prioritize, transparency-building measures, a call for which has been renewed in the tabling of Transparency International’s recent reports. Friends, on the other hand must be sensitive to connotations of conditionality, refrain from using regional unified approaches to policy such as Af-Pak, which the foreign office dislikes and ensure that aid does not undermine local accountability. Donors should also look beyond traditional modes of development assistance to help create frameworks that can incentivize private sector participation in development and infrastructure building; some core considerations in this regard have been flagged in these columns by the author on June 11, this year.
Most importantly, in the present drive to scale up, it is also important not to promise too much and be mindful of the fact that the Tokyo pledges remain fully unrealized. This package of support is not analogous to the Marshall Plan for many reasons, which have been highlighted by the author in these columns on April 28. This is a very different world; the donors are just emerging from the throes of a financial crisis and Pakistan is faced with many internal and external, conventional and unconventional security challenges. We need to use donors’ inputs and development resources to catalyze broad-based change rather than pursuing conventional time bound outcome based targets. Aid can only be a catalyst and that too, if effectively used. The ultimate onus of responsibility for making the quantum leaps needed in Pakistan today lies on the shoulders of those who govern it.
The writer is the founding president of the NGO think tank, Heartfile. E-mail sania@heartfile.org
Constitutional amendments
Published in The News International on September 19, 2009:
The Special Committee on Constitutional Reform is currently deliberating on the nature of constitutional amendments to be introduced through the 18th Amendment. Achieving balance of power should be an important outcome of this exercise. In addition, however, the potential within constitutional changes to foster improvements in the public policy domain should also be explored. Within this context, this comment draws attention to the need for updating the Principles of Policy, articulated in Part II, Chapter 2 of the 1973 Constitution.
Principles are a set of values that guide action towards desired goals; these are distinct from laws, which can compel or forbid behaviors. Defining the right principles can inspire the desired culture in articulating norms in policy instruments. The Principles of Policy in the 1973 Constitution were articulated at a time when the world was a very different place. Although these are relevant even today, other considerations have also assumed importance. Pakistan has signed up to many global normative frameworks since then—many of which have binding covenants. Many indigenous challenges warrant the inclusion of another generation of principles. The manner in which governance ineffectiveness has been pervasive, creates an imperative for covenants to set the right parameters in order. The opportunity to address these gaps should not be missed while framing the 18th Constitutional Amendment.
Chapter two stipulates 12 covenants as the Principles of Policy in Articles 29-40. These centre on the Islamic way of living; promotion of local government institutions; participation of women in national life; protection of the families and minorities; promotion of social justice and well being; eradication of social evils; discouraging prejudices; participation of people in armed forces and strengthening bonds with the Muslim world and international peace.
Some of these, to begin with do not sound like principles; they can at best be described as approaches or strategies. Additionally, there are eight missing principles of critical significance. These are being summarized hereunder.
Evidence is one of the most critical values in the domain of policy formulation. Similarly, transparency in conduct and accountability for actions is another critical principle—both are missing from the list. It is accepted that Government’s decisions are regularly challenged before the High Courts on the basis of absence of evidence and rationality and that detailed rules exist to guide judicial review of administrative decisions. Constitutional experts also draw attention to the fact that the requirement of evidence-based decision-making can be read into several other provisions of the Constitution such as Articles 4, 5 and 25, which are directly enforceable through inter alia Article 199. Experts also state that the requirement of transparency in administrative decision-making has been established through judicial precedent and may also form part of Article 4—which has been interpreted as the due process clause in the 1973 Constitution—and enforceable through Article 199. These explanations are accepted. Notwithstanding, absence of both the principles in the listing of the Principles of Policy is an omission. Framing these can signal an important intent, which is needed to move beyond the current culture of adhocism, personal preferences, and political expediency in the policy domain.
Outcome Orientation is another principle, which needs to be included. Policies, particularly in the social sectors have often supported ‘outputs’. Investment in infrastructure—hospitals and schools—is an example. The impact of such policies on actual goals or outcomes, which in the given example relates to better health and improved literacy, respectively is usually not optimally achieved. There is never an accountability drive to hold policy makers and implementers responsible for not achieving outcomes. Spelling out outcome orientation as a principle can signal its importance.
For a federating country, Solidarity should be defined as a Principle of Policy to signal that policy actions, while respecting autonomy of the federating units will not undermine cohesion and camaraderie. This can signal confidence to the small provinces at a time when provincial discord and separatist movements are taking root.
The difference between inequality and inequity should be brought to bear. The Principles of Policy refer to inequities only in the context of the employer vis-à-vis employee relationship in Article 38(a). The State’s commitment to addressing Inequities of power, money, and resources should clearly be reflected as an overarching principle as this forms the basis of social justice, which is one of the three principles, enshrined in the Objectives Resolution.
Technical and allocative efficiency, which are concerned with the “production of services at minimum cost” and “producing the right collection of outputs to achieve its overall goal”, respectively, should additionally also be included as principles, to signal the importance of optimizing resources in view of the present fiscal constraints.
Framing the right principles to guide decentralization/devolution is important. Presently, Article 32 and 37(i) relate to promotion of local government institutions and decentralization respectively. Article 140(A) makes it binding on every province to devolve political, administrative and financial responsibility and authority to elected representatives of the local government—a subject of great contention today. Although, it is not within the remit of the Principles of Policy to outline specifics in this area, the importance of two overarching principles needs to be emphasized. One of them is subsidiarity, an organizing principle, which means, “Matters ought to be handled by the smallest, lowest, or least centralized competent authority”. The other centers on community empowerment, without which decentralization cannot yield dividends.
In addition to the proposed 8 additions, it is recommended that existing principles be reframed in the following two areas.
The first relates to social justice and well-being. Articles 37(a), 37(b), 37(e) and 38(a-e), emphasize their importance. Article 38(c) and (d) reiterate the need to provide welfare for “those in the service of the country” and “those that are unable to earn their livelihood as a result of infirmity, sickness and unemployment”, respectively. Over the last decade, social welfare has been increasingly recognized as being synonymous with poverty reduction and social protection, whereas it is a much broader concept and links with the issue of enforceable social rights. Experts state that the impact of Article 25 read with Article 9 provides for enforceable fundamental rights. Although Article 9 in particular has been broadly interpreted in case law in this regard, there is lack of explicit clarity in this area, which must be addressed.
The second area relates to women’s empowerment. Currently, Article 34 relates to full participation of women in national life, whereas Article 37(e) stipulates women’s rights with respect to employment and maternity benefits. The world has moved significantly further along in this area since 1973 with women’s empowerment and matters related to access, rights and opportunities, including reproductive rights as being central to gender mainstreaming. Pakistan has made progress by signing the Convention on the Elimination of All Forms of Discrimination against Women (CEDAW), and enacting the Protection of Women (Criminal Laws Amendment) Act, 2006. The Principles of Policy should signal an overarching position, which should be a benchmark for policies in this domain.
In addition to these changes, a participatory mechanism is needed to periodically review the extent to which the Principles of Policy are adhered to in policy formulation and implementation. The recently tabled private member bill to add article 40(A) in order to enable the creation of a Council of Principles of Policy cannot provide this, given the usual public sector representation it calls for creating and the lack of a participatory approach. The Report on the Observance of the Principles—a constitutional requirement and part of the rules of procedure and conduct of business in the National Assembly—is in practice, treated as a mere formality. Faithful implementation of this requirement is important—the constitution envisages debate by Parliament, which if implemented in spirit would be a participatory process.
The writer is the founding president of the NGO think tank, Heartfile. E-mail sania@heartfile.org
Mixed Health Systems Syndrome.
Nishtar S. Mixed Health Systems Syndrome. Bull World Health Organ 2010;88:74-75. doi: 10.2471/BLT.09.067868
Synergizing health and population in Pakistan.
Nishtar S. Amjad S. Synergizing health and population in Pakistan. J Pak Med Asoc 2009;Suppl3:S3-20
Pakistan’s Health Population Mantra.
Nishtar S. Amjad S. Pakistan’s Health Population Mantra. J Pak Med Asoc 2009;Suppl3:S1-2
Governance—through the sugar crisis lens
Published in The News International on September 16, 2009:
The heartbreaking scene of 18 women succumbing to stampede whilst striving to get a bag of free sugar brings to attention the gravity of the ongoing commodity crisis. Such crises provide an insight into the regulatory capacity of governments and the level of governance effectiveness. Examination of the causes of the present sugar crisis can help in analyzing how that is the case.
Even under normal circumstances, sugar is a difficult domain to govern, with frequent tugs of war between the government, the sugar millers and growers. The constituency of growers demands higher price for raw material—their crop. The millers, on the other hand, complain about cost of production, other production related challenges, such as constraints imposed by the recent energy crisis and expect the government to protect them from sugar imports. Depending on who is stronger in the corridors of power—Pakistan’s feudal and elite dominated politics ensures representation of both groups—the decision making equation ends up favouring one, more than the other, but generally benefiting both. In addition to this complex interaction, inelastic demand of sugar is highly exploited by collusion between interest groups and regulators in food departments. All these factors lead to price increase, which is generally passed on to the consumer. When governments try to intervene and arbitrate by importing sugar, there is usually outrage by the manufactures and their dealers. As an outcome, governments often end up imposing higher tariffs.
The snapshot of this cycle shows that even under normal circumstances, when there are no crop catastrophes or any other supply disturbance, there is significant complexity in this area. This year round however, there were additional complicating factors. To begin with there was a shortfall in domestic production of the sugarcane crop. The government had no option but to plan for imports, albeit with much delay. It is widely believed that this was the result of undue influence of vested interest groups who could benefit from shortages in the market. The delay in importing sugar resulted not just in shortage in the domestic market and poor availability but also led to loss of precious foreign exchange, as by the time sugar was procured in the international market, its price had soared. Increase in the price of sugar in international markets was due to poor crop yield in major sugar producing countries such as India and Brazil, due to adverse weather conditions. As a result, the supply of sugar fell resulting in an upsurge of price all over the world. International price trends impacted price in Pakistan in a major way and exacerbated existing supply issues.
A closer examination reveals that the crisis is a manifestation of governance shortfalls at various stages in the governance cycle—at the level of setting policy directions, ensuring implementation of policies, exercising oversight, compelling accountability, effectively regulating and antecedent capacity deficits at all levels.
First, lack of transparency is manifest at various levels. Although there appears to be an interest in promoting integrity in the public sector at the bureaucratic level—the recent anti-corruption drive was a case in point—due attention is not given to conflict of interest in terms of major business involvement of cabinet ministers vis-à-vis respective ministries. The story of sugar is particularly illustrative in this respect. Many examples can be cited of landlord and/or miller ministers swinging decisions, or subverting the implementation of decisions for personal gains and/or patronizing interest groups. This factor is a critical impediment in the decision-making cycle, and adversely affects regulation. Institutionalized collusion between regulators and interest groups, and the resulting systemic manipulation further adds to the regulatory challenges.
In many ways, the sugar crisis is a classical example of state capture, where vested interest groups threaten the impartiality of public policy decisions; their undue influence in shaping state policies, furthered by patronage through political links diverts resources to the resourceful. The resulting outcomes can be devastating in the long term; state resources get channeled to the well connected, the rich poor divide is augmented, governance and regulatory capacity is exploited and attempts aimed at reform are systematically sabotaged. With respect to the present sugar crisis, the Competition Commission, has recently rightly emphasized that the government “must not provide any patronage to anti-competitive practices and measures encouraging ‘collusive behaviour”.
The system has limited accountability to hold functionaries accountable for undue actions. Accountability of politicians in Pakistan’s political system—where people are meant to hold politicians accountable for actions—can hardly bear fruit, owing to lack of awareness, rampant illiteracy, poor awareness of civic issues, and weak societal political culture. Poor illiterate people, who come from feudal strongholds—which is where most of the decision makers hail from—can hardly assess the impact of conflict of interest and regulatory collusion on public policy outcomes. Peer accountability in the Parliament on the other hand has also not been the norm unless motivated by personalized political objectives and seldom if ever comes to fruition with corrective measures of relevance to institutional strengthening. The new accountability framework embodied within the Holders of Public Offices Act 2009 (HOPA) if enacted in its present form, will unfortunately, bring no additional value to institutionalizing accountability and is likely to weaken existing mechanisms to compel accountability.
The accountability deficit exists not just for politicians, but also at the level of the techno-bureaucrats. For example, there can be many other causes of failure to take timely action to procure sugar in time. In today’s environment where information is available on a real time basis online, inability to take timely action raises many questions. Was the gap at the capacity level within the Ministry and departments to ascertain the brevity of the looming crisis? Or did the magnitude of the hurdles created by vested interest groups outweigh capacity and commitment within state agencies, interfering with their ability to perform? If the latter was the case, surely there is the need to analyze the impact of the current political dispensation on institutional performance and the decision making cycle. Although one is tempted to conclude that this factor is critical, the importance of other bureaucratic challenges should not be underestimated—in particular lack of decision-making prerogatives at mid-tier level, long winded procedures, the general lack of motivation to perform as a result of a number of disenabling institutional factors and rampant regulatory corruption. All of these are manifestations of poor governance.
Secondly, the other governance shortfall apparent in this crisis is the limitation of the government to take concerned economic measures and their resorting to stop gap arrangements, instead. It is accepted that these may be desperate well-intentioned moves; nothwithstanding, their impact has been negative—the crack down on the industry has disrupted the supply chain even further and the attempt to heavily subsidize sugar, is inadvertently furthering collusion. Thirdly, the intervention of the judiciary to benchmark price of sugar and the subsequent inability of the executive to implement the decision represents another unprecedented complexity in governance. Some may say that the judiciary should not involve itself in a purely economic mater; others will say this is a matter of access to essential commodities and therefore rights and hence within the Supreme Court’s purview.
In sum, therefore this crisis, like many others unveils many governance challenges, which need to be addressed coherently. Capacity to analyze the impact of policy decisions is critical to effectively managing such a complex process. Adequate capacity is also a pre-requisite for assessing the feasibility of alternative policy approaches, which experts have been raising in these columns lately. More importantly however, unless transparency-promoting reform is streamlined, sustained improvements cannot be expected. The writer has attempted to address the dimensions of such reform in these columns on August 15.
The writer is the founding president of the NGO think tank, Heartfile. E-mail sania@heartfile.org
Venice Statement on global health initiatives and health systems.
Atun R, Dybul M, Evans T, Kim JY, Moatti JP, Nishtar S, Russell A. Venice Statement on global health initiatives and health systems. Lancet 2009; 374(9692): 783-4
Nuancing national security
Published in The News International on August 22, 2009:
Reaffirming the commitment to national security can be a befitting commemoration of the country’s 62nd Independence Day. National security is defined as “the requirement to maintain the survival of the nation-state through the use of economic, military and political power and the exercise of diplomacy”. Conventional national security measures include maintaining effective armed forces and intelligence services, implementing civil defence and emergency preparedness measures and investments in critical infrastructure—all of them significantly important. However, security also has another dimension centered on human security as defined by the United Nations, according to which security scopes beyond state security to encompass other dimensions such as economic security, food security, environmental security, personal security and health security. Within Pakistan’s context, two other dimensions of security are additionally relevant—energy security and demographic security.
Sustainable state security is dependent on human security. A brief analysis of human security challenges in Pakistan’s context can help to underscore the magnitude of the problem and the importance of robust policies and institutions and effective governance in order to deal with these challenges.
First, Pakistan faces many challenges with respect to economic security as a result of a number of domestic and international factors. Despite some economic gains in the last decade, the level of human deprivation and poverty has increased. Several domestic issues—high food inflation, under-performing industrial and business sectors due to the global recession and crippling power shortages; fiscal pressures due to intensification of the war; deteriorating investment climate due to the internal security environment—have created unprecedented pressures on the economy. The global commodity and financial crises have further compounded the situation—in particular, the impact of the latter on trade and constrained resource mobilization options. While some sound macro-economic polices are currently being pursued, to address these challenges, experts are raising concerns about the rationale of others; the expected pressure on Pakistan’s import bill and trade balance because of increased import of oil to feed new power generators is notable in this regard.
Secondly, energy is the lifeline of economic development. Pakistan’s current 3000 MW shortfall is a stark reminder of institutional and political impediments. The former with respect to the colossal line losses and the latter in relation to politicization of major hydropower projects, given that 85% of the country’s estimated 40,000 MW potential remains untapped. Both these issues merit urgent attention. The government therefore needs to act at various levels to ensure energy security. In particular, affordable alternative energy options should be explored, in view of their inexhaustible nature, green imprint, prospects of off-grid maintenance and potential of delivery through the market.
Thirdly, the importance of water security can hardly be over-emphasized for a country with an agriculture-based economy. Pakistan depends on the Indus River Basin—the backbone of the country’s economy and the world’s largest contiguous irrigated system—to provide 90% of food production and 25% of GDP. However, this massive infrastructure is deteriorating and is plagued by issues related to diversion of water, competition between the provinces, inefficiencies of use and problems with irrigation and drainage. There is need for action at several levels—reforms to address underlying institutional weaknesses, investments throughout the system in order to rehabilitate critical assets, and an effective diplomatic intervention in relation to the Indus Water Treaty.
Fourthly, food security, which includes dimensions of availability, access and distribution, is of vital importance given its impact on economic growth, human health and productivity as well as political stability. The food insecurity-poverty nexus is pervasive in Pakistan. The report of the Task Force on Food Security recently set up by the government, has drawn attention to the diversity of responses needed to address this challenge and has underscored the importance of achieving an average agricultural growth rate of at least 4% per-anum in the next decade, an equitable system of food procurement, storage and distribution and effective safety net arrangements, in addition to other measures ranging from terms of trade, agriculture credit to institutional capacity for research, as being important in this regard. Effective governance capacity will be critical to implementing these important recommendations.
Energy, water and food security are interlinked with environmental security. Pakistan suffers many conventional environmental threats—water deficits, desertification, deforestation, soil erosion—in addition to the environmental impact of industrial effluents, municipal wastes, agricultural residues, and rampant and outdoor and indoor pollution in the face of poor implementation of the National Environmental Quality Standards. These play havoc with people’s health and have also been the subject of progressive public interest litigation concerning protection of the environment, in Pakistan, as has been alluded to in these columns on July 25, 2009. The projected impact of climate change, unfortunately, is expected to add to these challenges by adversely impacting the ecosystem—the natural water storage capacity of glaciers and monsoon patterns—adding further to the existing water, food and energy insecurity.
The fifth human security challenge relates to health security and threats from emerging and reemerging infections and public health emergencies of national and international concern, which can be biological or chemical in nature—terrorism related or accidental. In the last decade, SARS and Avian Flu caused significant social and economic losses. Evidence of virus entrenchment in Pakistan has been documented by the World Health Organization in its report ‘Human cases of Avian influenza-A (H5N1) in NWFP, Pakistan’, where a chain of transmission beginning with poultry-to-human transmission followed by probable human-to-human transmission was luckily un-sustained. The current unfolding of the Swine flu pandemic is dangerous as there is no way of predicting virus behaviors. Pakistan must put in place effective mechanisms, to comply with International Health Regulations 2005, to ensure that it is capable of thwarting these and other related threats.
The sixth security concern relates to demographic security. Pakistan is the sixth most populous country in the world with a rapidly burgeoning base of the population pyramid. There are two ways of looking at this situation. The abortive version of the Poverty Reduction Strategy Paper II, which was placed in the public domain for stakeholder inputs in 2005-06 envisaged this to be an opportunity and referred to it as the population dividend. However, this dividend in the face of many human and state security threats can also become a dangerous overload and fall prey to exploitation in extremist hands in a deeply polarized environment.
State and human security dimensions are therefore interrelated. Water and energy insecurity and political and civic instability, all of which are manifestations of poor governance, lead to economic and food insecurity; both of these have implications for poverty and deprivation; these in turn have a causal linkage with conflict and violence in a society. That in turn negatively impacts economic and human development and a vicious cycle is established.
Unless we deal with these problems holistically we will not be able to overcome state security challenges, which by itself has acquired many complicated dimensions in recent years. Pakistan’s national security institutional arrangements must therefore take all these threats into account.
Pakistan’s history of national security institutions is marked by four events. The National Security Council envisaged through the Order 14 of 1985, scrapped by the 8th Amendment; the 1997 Council on Defense and Security, which never convened; the structure proposed by the foreign office in February 1999, which could not come to fruition; and the National Security Council of 2004. Any new national security institutional framework, must pay careful attention to the interconnectedness of state security with economic and other dimensions of human security and ensure appropriate linkages between various domains. Ideally these should be reflected in the terms of reference, substantive functions and composition of the national security framework.
The author is the founder and president of the NGO think-tank, Heartfile. E mail: sania@heartfile.org
Anti-corruption reform
Published in The News International on August 15, 2009:
The release of Transparency International’s National Corruption Perception Survey, 2009, which assessed citizens’ perceptions as to the level of corruption in the four provinces of Pakistan, has sparked a debate about the prevalence of corruption in the country and the inter-provincial variations in the reported pattern.
First of all, it is important to appreciate that corruption assessment is a challenging area in governance diagnostics because of definitional ambiguities, complexities in categorisation, overlap of forms and its linkage with the cultural and social milieu, within which activities are perceived as being corruptive. Most of the commonly used methods for corruption assessment globally—of which perception surveys, expert opinions and measurements of indices of corruption, are the commonest—have their limitations. Perception surveys can be influenced by actual events surrounding data collection, whereas expert evaluations can be biased. There are other more robust methods for corruption assessment such as forensic investigations, economically modelled estimates and expenditure tracking surveys. However, these are usually not regarded appropriate for broad-based countrywide assessments owing to cost and time constraints. Perception surveys and expert opinions therefore, remain the globally accepted assessment tools.
Transparency International conventionally employs perception surveys. For its cross country comparative assessments, the World Bank utilises a composite indicator, which draws on data from perception surveys and expert opinions, whereas country rankings of the World Economic Forum are based on competitiveness reports from the respective countries. All of these data sources yield information on Pakistan regularly and consistently underscore the magnitude of the problem, as in many other developing countries.
Perception surveys from Pakistan-based organisations, such as the Pakistan Institute of Development Economics (PIDE) and Gallup, reinforce these trends. From time to time there is a tendency, particularly with incoming governments, to engage in forensic investigations of corruption charges against individuals as part of an effort to compel accountability and counter corruption. In many cases these have ended in long drawn judicial scuffles. What is more important is to take stock of broadly representative evidence, and recognise the magnitude of the problem as a first step towards building corrective and pre-emptive measures.
Corruption can be prevalent in any domain—in the political, state, business and NGO systems. Anti-corruption reform, therefore, is a complicated animal with many inter-related attributes, designed to address the determinants of corruption at various levels—frail governance structures of state institutions, weak political systems, thriving black markets and institutionalised patterns of collusion that sustain procurement graft. The list can go on. In an ideal world three requirements should be met in order for anti-corruption reform to be implemented.
One, a truly democratic dispensation, not just in the sense of majority rule but also in terms of striking the right balance between constitutionally-mandated institutions that uphold democratic values and democratic behaviours of consensus building and decision making. Two, a superior judiciary which remains un-politicised and a subordinate judiciary free from financial corruption; and, three, an executive that does not abuse the power of discretion and applies policies evenly. If these requirements are met, specific sectoral anti-corruption measures can be institutionalised with great success. Expecting all these things to happen all at once in the short term may be unrealistic. Pragmatically speaking, therefore, the government should focus on a few high potential anti-corruption measures on the premise that these would have a knock-on effect and catalyse action in the other areas, just as an open and relatively free media has had in recent years. The importance of six priority actions is being underscored in this regard.
First, Pakistan needs to fulfil its commitment as a signatory to the United Nations Convention Against Corruption (UNCAC) by revitalising the National Anti-Corruption Strategy which, despite its weakness, is a coherent framework and can be the basis of consensus-driven concrete plans of actions in terms of intra-agency sub-strategies. High-level political commitment is needed to revitalise this agenda and include its specific targets into the monitoring framework of ministries and government departments.
Secondly, there is the need for substantive changes in the legal anti-corruption and accountability frameworks. Currently, three draft proposals relating to the future of the National Accountability Bureau (NAB) are under consideration by the National Assembly’s Standing Committee on Law and Justice. One of these, the Holders of Public Offices Bill, 2009, intends to repeal the National Accountability Ordinance (NAO) and replace the NAB with an Accountability Commission. The writer has raised a number of issues in relation to the proposed changes envisaged through the statute in these columns on Jan 27 and May 25, emphasising the need to ensure independence of institutional arrangements and conference of a status that is immune from exploitation through political interference.
There are also many other concerns relating to this legal framework, particularly with regard to preferential treatment and other issues emerging as a result of its implementation, specifically in relation to strengthening the mandate of the FIA while it remains, in its present shape, an institution with many weaknesses. A robust legal and institutional anti-corruption framework can bring great value to mainstreaming transparency in state functioning.
Thirdly, some key oversight institutions should be strengthened—in particular, the Public Accounts Committee and the AG’s office. Recent improvements in the AG’s office should be sustained and further built upon. The potential within the Public Accounts Committee can be harnessed with the leader of opposition in its chair, albeit with the right technical inputs and civil-society engagement. The Public Accounts Committees also exist within the framework of the local government system but have not been made to function as a tool for strengthening district oversight and accountability. Although their fate is dependant on the overall decision relating to the local government system, every effort should be made to retain and strengthen institutional frameworks that can compel accountability.
Fourthly, rather than the punitive, investigative and sanctions-oriented approach to dealing with corruption in the private sector, the focus should be on leveraging the potential within competitiveness to counter organised vested interests and ensure that businesses have a level playing field. Pakistan’s Competition Commission should be incentivised to act as an active engine in order to build safeguards in the market environment.
In the fifth place, a twin agenda relevant to the executive branch of the state can help to achieve efficiency whilst at the same time act as a safeguard against collusion. Critical investments are needed in technological applications in the management and public expenditure tracking streams. Alongside, some initial steps must also be taken to promote integrity at the executive level; although civil service reforms is a long-drawn agenda and while the system eagerly awaits the much-needed deeply rooted action in this area, improvements can be made by ensuring respect for merit and tenure security and improving accountability of decision making.
Lastly, it is important to review the Freedom of Information Law, 2002. Freedom of information is not about media freedom. It has to do with access to information and disclosure which can enable public discourse. The right to information is a crucial underpinning of participatory democracy. Promotion of open government and maximum disclosure can be the single most important step towards eliminating corruption. If this is coupled with the right awareness-building measures for citizens that empower them with knowledge of what laws mean and the implications of information on their lives, sustained improvement with respect to transparency in governance can be expected over time.
The author is the founding president of the health sector NGO think tank, Heartfile. E mail: sania@heartfile.org
Devolution reform
Published in The News International on August 08, 2009:
The fate of the devolution initiative is likely to be decided by the end of this year, regardless of the presidential sanction to the provincial draft proposal—currently in the pipeline—given that the Local Government Ordinance will stand omitted from the Sixth Schedule of the Constitution, after six years of passage of the 17th Amendment in December 2009. A turf battle is imminent in the wake of the most likely decision; provincial governments have already stated that they will completely abolish the current system whereas proponents of the devolution initiative, citing 140-A of the Constitution and terming appointment of the administrators, unconstitutional are likely to turn to courts. The beginnings of that scuffle are already evident. The ensuing impasse is likely to have implications for the working of the government, the development of democracy, the mandate of the judicial system and citizen’s empowerment—all at the grass roots level, where government matters to the poor and marginalized.
Within this context, this comment is aimed at drawing attention to the need for impartiality and evidence-guided decision making in relation to a way forward. A comparative evaluation of impact of the local government system vis-à-vis the divisional system in relation to social, fiscal, administrative and political outcomes can yield important evidence, which can inform policy. Although a case control assessment was not part of the design of the devolution initiative, as the reform was implemented all over the country at one time, evaluations and assessments conducted subsequently can yield meaningful information. The Federal Bureau of Statistics conducts yearly surveys, such as the Pakistan Social and Living Standards Measurement Survey (PSLM); this can yield evidence of impact and social outcome trends overtime, before and after implementation of the devolution initiative. Sequential surveys of the Center for Poverty Reduction (CPRID) and CIET (social audit surveys in 2002 and 2004) can yield similar information. There is a vast body of evidence in the ‘pre’ and ‘post’ studies on local revenue by Provincial Finance Commissions. It is important to triangulate information from all these sources to assess impact on outcomes and outputs, before coming to any conclusions.
The devolution initiative was not perfect; but scrapping something as major as this without a thorough analysis, would be unwarranted. Devolution and decentralization is a complex process involving transfer of authority and a range of transformations in the public sector; effective implementation of the reform necessitates adequate capacity to understand and the ability to garner support of stakeholders to implement changes in a complex environment. The National Reconstruction Bureau was mandated to develop norms, standards and guidelines, which could have assisted with the change, but there appeared to be limited will to operationalize such changes in Pakistan in the true spirit. Additionally many prevailing systemic issues were an impediment to its implementation; some of these merit a mention.
First, the Local Government System was theoretically designed to be a departure from the post-colonial style of district and divisional administration to a paradigm of grass roots governance with the expectation that power will be in the hands of the elected representatives from a grass roots base. Devolution/decentralization of government was meant to open avenues for accelerating progress in social service delivery and enhance public sector effectiveness by bringing those responsible for delivering services close to intended beneficiaries and making them accountable. The system was also expected to allow local voice to set priorities, encourage innovation and improve efficiency of resource allocation. These were important envisaged endpoints. In actual effect, anecdotal evidence and observations from the field show that the performance of the local governments fell across a spectrum—from good at one extreme to poor at the other. Of course, there can be no generalizations, but observations in some districts were indicative of improvements, primarily as a result of increase in resources and their timely utilization; the latter enabled by a decentralized system of planning and decision-making. In many other districts, however, that wasn’t the case and the initiative fell prey to elite capture and Pakistan’s feudal-dominated grass roots politics. The fact that the Nazim was in fact selected to be elected by an assembly that he/she was not an elected member of, was one of the most significant weakness of the system and opened avenues for patronage, in some districts. This coupled with poor application of the mechanism to hold the Nazim accountable, led to abuse of the system and fueled graft in some districts. This embittered the provincial administrations even further who already alienated by the loss of administrative levers now found that another layer of government had access to public resources; this threatened individual interests in a system where collusion is deeply institutionalized. In some poorly performing districts, the dynamics of control also did not desirably change at the grass roots level and the potential within the initiative to strengthen the societal political culture and empower citizens, could not be fully harnessed. It would be interesting to see how these core weaknesses are addressed, by the current political dispensation, when/as it gets to making changes.
Secondly, the system attempted to abolish the divisional tier and empowered districts by granting them financial and administrative autonomy. Although empowering the districts was a desirable step, abolition of the divisional administrative and technical hierarchy had implications at various levels—in particular, capacity at the level of federal/provincial institutions to handle data and information, which had not been sifted and/or consolidated at an intermediate level. These implications could not be adequately addressed as the devolution initiative got implemented. With careful attention to capacity building at both ends, some level of incremental progress could have been made. Thirdly, the system abolished Executive Magistracy. Although the approach was in line with the constitutional provision to ensure independence of the judiciary, it created a gap at the local level, as concomitant investments were not made to bridge prevailing gaps in the judicial system.
Some conclusions can be drawn from this account. First and foremost, it must be recognized that a system mandated to restructure the local political and administrative arrangements cannot be fully successful if the central systemic issues in state functioning and political systems continue to prevail. Restructuring the system of governance and political dispensation at the district level should therefore be accompanied by the much-needed reform of the political, judicial and broader public resource management systems, at the federal and provincial levels, in order to be effective.
Secondly, administrative restructuring should never be used as a lever to consolidate the administrative and political power base and a basis for controlling resources and using power for patronage, but as a means of strengthening grass roots democracy and a mechanism for effective delivery of services. Thirdly, existing evidence points to specific action in certain areas. For example, the issue of strengthening accountability and capacity at multiple levels and the possibility of crafting a useful divisional role, particularly with reference to technical functions needs to be carefully taken into consideration. Similarly, there is the need to make use of the sizable allocations for Community Citizens Boards as an instrument to empower local communities and strengthen avenues for demand side financing to support grass roots development.
The current opinions about the governance reform are largely based on anecdotal reports, personal and group perceptions and isolated observations, which have been widely generalized and in some cases also politicized. In charting a way forward, provinces must refrain from making sweeping changes; the answer is not in scraping the current system and installing something de novo, but using evidence to shape policy in order to create the optimal balance between authority, responsibility and accountability. In many ways this will be a test of leadership capacity at the provincial level. Provinces have the right to restructure the local government system according to the mandate in Article 140-A, which seeks to implement Article 32 of the Principles of Policy. But that prerogative needs to be exercised with great prudence.
The author is the founding president of the health sector NGO think tank, Heartfile. E mail: sania@heartfile.org
Judicialisation of rights
Published in The News International on July 25, 2009:
The Petroleum Development Levy (Amendment) Ordinance, 2009, which offset the Supreme Court’s suspension of the imposition of the carbon surcharge was challenged on the basis of the Constitution’s Articles 2A, 4, 5, 8, 9, 25, 37, 38(d), 77 and 89. The resulting difference of opinion between the three pillars of the state—the executive, the judiciary and the legislature—raises some important issues to be resolved; both with reference to their respective constitutional domains as well as the matter of human rights and their legal enforcement.
Many of us perceive human rights as belonging to the narrow domain of civil liberties, political rights, freedom of expression and equality before law. But there is much more in the remit of Rights than there is in these areas. The definition of Rights embodies economic and social rights and the right to life and education; several international treaties and human rights instruments, enacted after 1966 have attempted to further expand this definition.
The recent advent of judicial activism in Pakistan in general, and adoption of a progressive interpretation of rights in this case, in particular, has largely been a response to domestic situations; however, in many ways, it is also, part of a burgeoning trend, internationally. Some observations from other countries, particularly Latin America and the UN system are instructive in this regard. The example of health as a human right can illustrate this point further.
Currently, there are 115 countries in the world, which recognize the constitutional right to health; Chile provided the first constitutional recognition in 1925. Over the last two decades many Latin American courts, from both civil and common law jurisdictions, have handed down landmark decisions, guaranteeing access to treatment affecting thousands of individuals. In South Africa, since the constitution came into force in 1994, health rights together with housing rights have become the most important socioeconomic rights cases considered by courts. The movement of judicialization of health rights has particularly been fueled by challenges that states face to provide antiretroviral treatment (drugs used for the management of HIV and AIDS) in the face of the HIV and AIDS epidemic and the treatment of other diseases, which cause catastrophic expenditure. Cases such as the Minister of Health vs. Treatment Action Campaign 2002 (the TAC case) and Soobramoney Cases in South Africa illustrate this point.
Brazil is another example of progressive interpretation of rights. The Brazilian constitution of 1988 granted the right to health to all its citizens and mandated the creation of a National Healthcare System; in 1996, legislation granted universal access to antiretroviral treatment. Following that, patients across Brazil have been turning to courts to access prescribed drugs and since then lawsuits, all over the country have secured access to antiretroviral treatment for thousands of people. In addition to individual treatment, public interest litigation cases impacting on the right to health have also been those concerning protection of the environment, particularly in judgments from South Asian courts.
From a study of all these examples, one thing is evident: where right to health is specifically guaranteed under the constitution, courts have to wrestle with challenging issues; however on the other hand, the lack of express constitutional entrenchment of the right to health in domestic law is not necessarily a bar to consideration and enforcement, as is the case in Untied Kingdom and Canada.
Insights from another domain are also relevant. Last month (June 2009), the United Nation’s Human Rights Council adopted a landmark resolution acknowledging that preventable maternal mortality is a human rights issue and that national and international efforts to protect women worldwide should be scaled up; more than 70 UN member states co-sponsored the resolution, Pakistan being one of them, despite initial reluctance.
The background of the diffidence of some countries to subscribe to a rights-based approach to social and economic issues is important to understand in a contemporary context. The Universal Declaration of Human Rights (UDHR), which represented a watershed in the history of human rights, adopted by the United Nations General Assembly in 1948, initially intended only one instrument. Later, it was bifurcated into two distinct and different covenants. A covenant on civil and political rights (International Covenant on Civil and Political Rights [ICCPR]) and another covenant on Economic, Cultural and Social Rights (International Covenant on Economic, Social and Cultural Rights [ICESCR]). The UN’s committee on Economic, Social and Cultural Rights emphasized that it was upto states to give effect to the rights containted in the ICCPR.
Many states, which supported the seperation and which were ultimaltey sucsessful in obtaining a division were of the opinion that the two sets of Rights could not be equated. According to them, the connotation of ‘social and econonomic prerogatives’ of citizens could not be labled as rights since their realizaition was interlinked with a number of considerations—the indigenous body politic, availability of resources and idealogical and geo-political considerations. In their opinion, these could more appropraitely be labelled as aspirations or plans and not rights and could not be the basis of binding obligations, in the way that civil and political rights needed to be. Furhtermore, they argued that the means of enforcing the former were very different from the mechanims that were needed to ensure compliance with the latter. Other countries had other specific interpretations of human rights and argued strongly for the inclusion of all rights in the framework. The UN therefore, found a middle ground and the rights enshrined in the UDHR were split into two separate covenants, as previously stated; this allowed states to adopt some rights and derogate others.
Since then and in line with this trend there has been a perception in many countries that socio-economic rights are not enforceable through courts. In Pakistan also, it was previously perceived that whilst the Principles of Policy of the Constitution form the basis of the right-based approach, they are not enforceable through courts. However, over the years, a series of court judgments have refuted this notion, arguing that since the word life has not been defined in the Constitution, it does not have to be restricted to mere existence in contradistinction to death but should include within its ambit, any hazard to life including ill health, both in individual as well as in communal settings. This has particularly been the case in the Syed Mansoor Ali Shah vs. Government of Punjab [2007 C. L. D.533] case and the case of Miss Shehla Zia and others vs. WAPDA [PLD 1994 Supreme Court 693]. In these cases, the court achieved equivalence between civil and political rights and their social and economic counterparts through the application of an expansive definition of right to life. These decisions set a precedent and since then there have been many other such progressive decisions.
The case of the petroleum levy is therefore, not the first time courts have attempted to legally enforce social rights in Pakistan. But in today’s Pakistan, with an escalating trend of judicial activism, this decision has a different connotation. Does this signal the ushering in of an era of progressive jurisprudence, progressive interpretation of rights and public interest litigation with courts ordering compensation, and demanding concrete immediate steps? Only time will tell if that is the case. However, if that does happen, we must be mindful of the enormous administrative and financial burden on the government and the capacity of the judiciary, which in itself needs to be—and is on the way to being—reformed. It is hoped that judicialization of social rights can usher in a new chapter in the history of social sector reform in Pakistan where governments will be forced to weigh the impact of any decision on the grounds of equity and social justice.
The author is the founding president of the NGO think-tank, Heartfile. E-mail sania@heartfile.org
The IDP-governance link
Published in The News International on July 16, 2009:
There is hardly any problem in the country, which cannot be tracked back to challenges and weaknesses at the level of governance—the crisis of the internally displaced persons (IDPs) is certainly no exception. Both the technocratic and political aspects of governance, inclusive of policy directions at various levels, to the dynamics and pitfalls of the public management process, have deeply impacted the IDP crisis—right from the manner in which it evolved to the style in which it was managed. Now that the IDPs are reported to be on their way back to being settled in their home communities, it is opportune to analyze impediments to the relief operations. A careful review will draw attention to most as being linked with limitations at the level of governance. These insights would be valuable not just in relation to disaster preparedness for the future, but would also be critical for rehabilitating the IDPs, and shifting the mode of assistance from humanitarian to development, which is the next imminent step.
First, a humanitarian crisis was clearly inevitable, ever since the theatre of war widened since the end of 2008; according to some experts, the writing was on the wall as early as 2007. The United Nations repeatedly issued warnings during this time span. Although the scale of the mass exodus—over two million people, equal to the entire population of Kuwait was displaced—could have been underestimated, the government’s emergency apparatus must have envisioned that a significant humanitarian crisis was looming. Surely, the government must have made some plans, preempting the situation. And if it was unable to do that, it must analyze gaps in its own capacity and the factors, which prevented it from doing so. Although it is acknowledged that establishing relief camps in preparation would have signaled the imminent operation; notwithstanding, adequate measures could have been taken to provide transport to rescue people to safety. If that didn’t happen optimally, someone is responsible for the lack of timely decision-making or seeing through that decisions were implemented, if indeed they had been taken. This is precisely what effective governance would call for. In a way, the IDP crisis was a test of the country’s institutional capacity to respond with relief measures in a crisis situation. If it didn’t perform well in an anticipated situation, the likelihood that it will respond in the event of an unforeseen crisis would be very slim. With the way things stand, this may not be the last crisis of its kind; we must therefore, review evidence of our intransigency in the given context, with concern.
Secondly, it is important to recall the investments that were made towards creating a National Disaster Management Framework in the aftermath of the October 2005 earthquake; the framework comprised of policy, legal and institutional arrangements and implementing strategies and programs. The National Disaster Management Ordinance, 2006 was promulgated and the National Disaster Management Commission was created to oversee its implementation. The statute mandated the creation of the National Disaster Management Authority. Subsequently, the Provincial Disaster Management Authorities (PDMA) and the District Disaster Management Authorities (DDMA) were created. The National Disaster Management Framework used a holistic definition of ‘disaster’—one inclusive of man-made catastrophies and therefore is relevant to the situation with reference to the IDPs, even though the framework doesn’t refer to war and its consequences. As opposed to this however, the role of this framework in the IDP context was not clearly and fully evident and the creation of other parallel institutional entities raised many questions. For example, why was there the need to appoint a Provincial Relief Commissioner in NWFP under the National Calamities (Prevention and Relief) Act of 1958, despite the existence of the PDMA; could the latter not “ensure quick response related to matters” as was stated whilst justifying the creation of the former; why could the PDMA not deliver on this premise? Which factors led to the creation of the Federal Special Supports Group? Was the performance of the post-earthquake institutions not optimal? Or was it a leadership issue or a question of mandate or capacity? Were there any political hurdles or resource management issues? Or is this yet another example of the country’s tendency to create institutional arrangements and hierarchies without appropriate resources to ensure that they can optimally function. Was there no evaluation of performance, no process examination, no efforts aimed at drawing on lessons, which could have provided insights into the limitations that post-earthquake structures faced? If we continue to give performance evaluation—another important attribute of governance—the level of importance we currently do, this pattern of institutions-failing-when-needed, will be perpetuated. Nowhere is this more dangerous than in the area of emergency relief.
Thirdly, the IDP crisis should force us to rethink the approach to local governance. The Government has postponed the Local Government elections in a major policy decision on July 9; with this decision, the uncertainty, which existed about the fate of this initiative, has further exacerbated. However, this is not a chapter that can be wrapped up that easily, given that ‘Promotion of local government institutions’ is enshrined in the Principles of Policy of the Constitution and has been stated as a priority in political party manifestos of the ruling parties. Insights into the functioning the local government system are therefore needed to craft a way forward. Within this context, the relief operations have brought to the fore, many weaknesses. It is increasingly apparent that there is some level of centralization of decision-making in the ‘decentralized system’ and that, ’empowerment of local communities’ as was originally envisaged, hasn’t happened across the board. The District Coordinating Officers are not always seamlessly linked with the sub-district officers, who are in a better position to gauge local requirements and identify those in need. Union councils, which are the lowest tier of local government, were in a better position than provincial governments to identify IDPs that had chosen to settle outside of camps since they are supposed to have better links with the families and schools hosting the IDPs. However, this tier was neglected in relief operations. Moreover, mechanisms were not in place to enable host communities to determine their own needs and priorities and citizens were not empowered to demand greater accountability.
In the fourth place, weaknesses in accountability mechanisms posed additional challenges to implementing relief operations. In an environment where collusion in procurements and pilfering from the distribution chain were endemic, the impact of relief operations, which inherently hinged on stable supply chains, became a challenge. In such an environment, any promising initiative can be undermined. The federal government is currently giving priority to IDPs to get assistance from the Benazir Income Support Program—a cash transfer program, which uses a smart card with biometric features embedded—for providing assistance to economically and socially vulnerable women. The use of technology has brought value to this process; however, patronage in selection and tampering with criteria can undermine its usefulness.
In a nutshell therefore, in the absence of effective frameworks of governance not only can relief operation be jeopardized, the viability of long-term rehabilitation, reconstruction and development efforts can also be threatened. Comprehensive governance is not just essential for development and restructuring, it is also critical for targeting assistance beyond humanitarian support in order to catalyze economic activity and support independent economic generation. The ability and capacity to govern also underpin the success of constitutional, legal and political reforms, which are urgently needed to address the underlying causes of conflict, and without which significant success cannot be achieved. If communities cannot be rehabilitated and reunited in their homes where rule of law is enforced, human rights are respected and economic activity renewed, the displaced cannot become constituencies of peace.
The author is the founding president of the NGO think-tank, Heartfile. E-mail sania@heartfile.org
Budget 2009-10 and the health sector
Published in The News International on July 06, 2009:
The health sector was marked by six policy highlights in the expansionary fiscal policy of the government in the federal budget for 2009/10. These policy dimensions center on the following: scale up of the existing budget; pronouncement of a health insurance scheme; enhanced allocations for the two key national public health programs; a dedicated allocation for an action plan for emergency diseases; changes in tariffs for some essential medicines and increase in the excise tax with regard to tobacco. This comment briefly touches upon the context of each fiscal policy decision.
First, there are many caveats to the aggregate increase in allocation, which by itself is a positive step. The writer has raised the questions of quality of expenditure, the issue of the allocation-disbursement-expenditure disconnect and the tendency to scale back initial allocations towards the end of the year in view of fiscal deficit constraints, as potential impediments in this regard, in these columns on June 23rd 2009. In the budget of 2009/10, reliance on foreign assistance to finance much of the social sector outlay is an additional threat. However, even if the increased allocation is actually accrued to public financing for health, it would not represent a quantum leap. According to the Federal Bureau of Statistics’ National Health Accounts, which have been released in May this year, public spending for health amounts to $14 per capita and with this increase, will only take this up to less than $16 per capita—still far short of the $34 per capita, considered as minimum by the World Health Organization to deliver essential services in a country. Increased allocations for health must therefore be seen in the context of these realities.
Secondly, the budget documentation refers to the launching of a health insurance scheme. The government must carefully take into consideration, the context and imperatives of any envisaged scheme and their capacity in this regard. Majority of Pakistan’s population who need to be secured for health are in the informal sector, which makes it impossible to levy payroll taxes or bind employers to make contributions; unless the state is willing to make per-capita contributions and inject significant additional resources to underwrite costs, comprehensive health insurance reforms will not be possible. Additionally, the institutional infrastructure to ensure provider buy-in and administer policies in far-flung areas is weak and most packages, which are currently being piloted, do not cover catastrophic expenditure on health, which is where the actual problem with health financing lies in Pakistan.
The question of health insurance therefore has to be viewed from the broad lens of the need to cover the population for essential services through public financing; the government should adopt a locally-suited approach and pursue a combination of measures to increase public financing in this regard. Increasing revenues in order to better equip basic health facilities so as to facilitate access to care, free at the point of service and augmenting pools of funds to finance waivers for those in the informal sector, who run the risk of spending catastrophically, should be part of this approach. Social health insurance can then be used in combination with these health financing arrangements to expand the base of existing health protection arrangements.
Thirdly, more than 50% of the allocations this year round have been earmarked for the two programs—the National Program for Family Planning and Primary Health Care (the Lady Health Worker program) and the Expanded Program for Immunization. Although these programs have had some level of success—e.g. increase in immunization coverage from 35% in 1991 to 47% in 2005 and better coverage of skilled birth attendants in LHW covered areas—progress has been unacceptably slow. Here it is important to appreciate that the performance of these programs is deeply interlinked with broader issues. These include but are not limited to problems with social sector service delivery, issues of public finance management and procurements, the federal-provincial-district disconnect with respect to roles and responsibilities, and broader issues of governance in relation to staff deployment, oversight and accountability. The programs are additionally federally controlled in most instances; transfer of resources from the federal government to the districts, outside of provincial-district accounting channels has led to lack of ownership of these programs by the provinces. Confusion around decentralization further compounds these challenges. We therefore need to be very pragmatic with the level of achievement to be expected with the modest increase in resources, while overwhelming structural issues continue to prevail.
In the fourth place, allocations have been earmarked for an ‘Emergency Plan for Diseases’—presumably for emergency preparedness in health. These allocations should be used for ensuring epidemiological security in the wake of threats from emerging and re-emerging infections and public health emergencies of national and international concern.
There is some evidence of recent increase in occurrence of emerging and re-emerging infections in parts of the country. The emergence of avian influenza in the poultry belt of NWFP and the chain of transmission beginning with poultry-to-human transmission followed by probable human-to-human transmission is particularly important in this regard. Virus transmission in this case was fortunately un-sustained; however, entrenchment of the virus means that more human cases will occur in the future. Each initial human case gives the virus an opportunity to improve human-to-human transmission and thus develop into a pandemic strain. Pakistan must take this evidence seriously and put mechanisms in place to ensure that its public health system is capable of responding to disease outbreaks. As a signatory to World Health Organization’s International Health Regulations 2005, Pakistan is bound to ensure compliance with its stipulations.
The world is still under the threat of the influenza pandemic and if it is hit against the current backdrop of the financial crisis, the impact could be truly catastrophic. Pakistan must be better prepared as part of its collective global responsibilities and ensure that allocated resources are used strategically to step up surveillance, stockpile medicines as needed, set up appropriate laboratory infrastructure and meet legal requirements to report notifiable diseases.
In the fifth place, concessional tariffs on some pharmaceutical raw materials are noted. However, the budget is silent with respect to many other measures, support for which could have been signaled and allocations earmarked in an attempt to curb the menace of spurious drugs and make drugs affordable, accessible and of good quality. The writer has outlined some key policy interventions in this connection in these columns on February 14, 2009, drawing attention to the need to resource and reengineer oversight and regulatory arrangements.
Finally, it is noted that tobacco excise duty is being increased. Tax policies as a tool to control tobacco consumption are based on the premise that the demand for tobacco is strongly determined by price. It needs to be explored if the strategy can be effective in Pakistan in terms of impacting consumption patterns, given its limitation to impact the illicit cigarette manufacturing sector; furthermore, increase in excise duty will augment the government’s reliance on tobacco taxation as a source of revenue, which in turn could influence advertising and other restrictions.
In sum therefore, increase in aggregate allocations for health in the federal budget is a welcome trend. However, the likely impact of this increase is limited given the huge gap that exists in public financing for health within the country and inherent issues at the health systems level. Concerted long term action is needed to restructure policies, laws, institutions, norms and regulatory and oversight mechanisms in the health and related sector in order to improve health status of the people of the country.
The writer is the founder and president of the NGO think tank, Heartfile. E mail: sania@heartfile.org
Equity, social justice and the social sector
Published in The News International on June 22, 2009:
The Finance Bill 2009, which gives effect to the financial proposals of the federal government for a year, is the government’s key instrument of fiscal policy and in many ways, a reflection of its policy stance to achieve stated endpoints in many state domains. Within that remit, the purpose of this comment is to bring to the fore some considerations relevant to equity, social justice and the social sector, with a view to generating a debate on the subject, within the context of the forthcoming parliamentary sessions that will now convene to deliberate on the Finance Bill. Three points are being articulated in this connection.
First, it is important to recognise the value of budgetary empirics; within that ambit, a paradox is evident straight away. Last year, we had the largest-ever cuts in public-sector development expenditure (PSDP). This year we have the largest-ever PSDP allocations. From the information in the public domain, it can be deciphered that last year’s PSDP scale-back, though partly the result of unforeseen crises could also be attributed to overestimated projections of foreign assistance; this time round, development appears to be financed through foreign assistance to a large extent and there appear to be no guarantees in place to ensure that the budgetary outlay will not be met with the same fate, as the year before.
By and large, some level of attempt to target welfare is evident in this budget. Technical limitations notwithstanding, this is manifest in the following: a) social security to another segment of the population—haris and the internally displaced—and health security envisaged through the recently announced health insurance scheme; b) income support to low-income households through a scale-up of the Benazir Income Support Programme, broadening the numeric base of microfinance and launching of the one-person-per-household-trained scheme; and c) the emphasis on infrastructure through the public works programme. A careful analysis is needed to examine if the impact of indirect taxes—for example, the carbon levy—outweigh the envisaged benefits of these interventions. In many ways, it is the social impact of policies in other domains that are more important in determining social outcomes.
Within the ambit of empirics, the budget is—and has always been—oblivious to improving returns on spending; the quality of expenditures, equity in utilisation and effectiveness of targeting are equally, if not more important considerations compared to aggregate allocations. The allocation-disbursement-expenditure anomalies, which negatively impact the ability to expend and the quality of expenditures—decision-making delays and lack of accountability thereof, centralisation of decision-making, onerous finance and administrative procedures—deeply impact performance of the social sectors; in addition, graft and systemic pilferages compromise public expenditures in a highly-constrained environment. Unless there is a system of gaining insights from an ongoing process of astute impartial analysis of the fiscal policy cycle, factors that undermine the impact of fiscal inputs cannot be appreciated.
Secondly, the potential within a Finance Bill to promote equitable allocation of resources cannot be fully harnessed, given that the country does not have a consolidated all-encompassing Social Policy Framework. This points merits further elaboration.
Pakistan has a range of policy guidelines, which constitute the individual elements of a social policy; these include respective policies on housing, labour protection, environment, health and education. However, Pakistan does not have a consolidated social policy embodied within a social justice framework, which addresses the range of dimensions sets forth and mitigates against the impact of policies in other sectors on social outcomes. Those in the establishment can argue against the aforementioned argument, “Pakistan does not have a social policy,” by referring to the Social Protection Strategy of the ministry of social welfare, stating that the government’s obligation to chart a social policy has been fulfilled or by referring to social sector programs and the delivery of services.
A social policy is much more overarching and all-embracing than each of these. Programmes in the social sector and services are just one component of the framework. Social protection is a concept embodied within a social policy, but it is not a substitute for it and the latter is clearly more overarching. Pakistan’s Social Protection Strategy, is focused on “supporting vulnerable households in managing hazards and risks.” Although it is true that the original motivation for the expansion of welfare services should be to help the poor, welfare does not have to be restricted to the poor. It is now well established that anti-poverty policies have their limitations in reducing unjust social disparities and therefore action beyond the poor is needed to deliver social services as a public good. An all encompassing social policy, overall responsibility for implementing the policy and clarity in relation to several normative parameters—range of services and their coverage; the choices concerning those services, the means of their provision and mechanisms of their financing are therefore a prerequisite before the potential within a budget statement can be leveraged to target equity through expenditures. One expects these points to be raised on the floor of the Parliament instead of the deeply polarised, politicised and charged discussions, which usually characterise parliamentary debates.
In the third place, and most importantly, the success of a fiscal policy implemented through a budget instrument is deeply dependent on the quality of governance and institutional ability to effectively and transparently implement policies in their stated spirit. This is where the biggest gap lies in Pakistan. Exceptions notwithstanding, issues of capacity and performance are widely recognised in Pakistan’s public management process; years of under-funding of state institutions and the culture of patronage and collusion have eroded the technical capacity of our ministries. Limited accountability, poor governance and mismanagement have led to the institutionalisation of a number of behaviours detrimental to equitable deployment of resources. As a result, evidence-guided choices are bypassed, motivations other than welfare of the people dominate decisions and considerations other than equity and social justice become the cornerstones of institutional performance.
These considerations can impact the performance of any program—the Benazir Income Support Programme is not structurally immune from political patronage, even through a well-designed scoring and evaluation system appears to be in the pipeline for deployment; the envisaged health insurance scheme will be serviced by a crumbling state health machinery; the public works scheme will be implemented by agencies where graft is common and though fiscal measures have been promoted for agriculture in the current budget, they are likely to get increasingly skewed towards the elite, if measures are not taken to build conscious safeguards.
In sum, therefore, we need to be pragmatic with our expectations with respect to what the Finance Bill can achieve by way of improving the social outcomes. Though there have been aggregate increases earmarked, they aren’t sustainable and guaranteed revenue sources. Moreover the policy and institutional parameters, which enable the translation of fiscal policy commitments into outcomes, suffer from many gaps particularly in the present environment of governance. Unless these change, major strides cannot be made in the social sectors.
In the run-up to its adoption, the Finance Bill will undergo many changes, particularly as they relate to prerogatives, permissions, tariffs, subsidies, etc. Those that have the ability and access to voice their opinion in the corridors of power are likely to get their interests protected. However, majority of those who need direly to benefit from Pakistan’s fiscal policy are neither aware of its existence nor have the means of voicing their concerns. The barest minimum we can do for this segment of the population is to protect the social sector budget from a scale back, which usually transpires during the course of the year as a result of fiscal deficit constraints.
The author is founding president of the NGO think tank, Heartfile. Email: sania@heartfile.org
The forthcoming budget and the public-private mantra
Published in The News International on June 11, 2009:
The government has decided to increase spending in the development sector in the coming year as is evidenced by the expansionary fiscal policy adopted in the forthcoming budget for the year 2009-10. Approval of the highest ever Public Sector Development Program by the National Economic Council comes at a time when many fiscal space constraints are evident—decline in revenues, competing priorities particularly in the wake of the ongoing security situation and efforts to curtail the fiscal deficit in order to keep it within stipulated limits. The rationale for the approach has fueled a debate amongst subject experts—a positive development indeed given the potential within constructive and substantive technical dialogue to shape policy decisions in national interest.
The purpose of this comment is not to dwell on that debate but to draw attention to a related issue of strengthening the public-private interface as a policy option to assist the government in achieving the development objectives envisaged in the budget. Two areas appear important in this regard.
The first area is infrastructure development. In today’s environment, investments in infrastructure are critically needed, as they can generate economic activity and create employment. In the 1930’s, one of the factors responsible for United States’ recovery from the Great Depression related to Roosevelt’s policies of investment in huge public work schemes, which enabled the generation of employment. Efficient infrastructure can also boost economic recovery through promotion of local and foreign investment and business productivity and expansion—all of which are needed in today’s context.
The currently prevailing power shortage—though attributable to some extent to the issue of circular debt, the decades-long intransigency to invest in water reservoirs and the crumbling state of public transport and social infrastructure in the country also reiterate the need to invest in infrastructure. Pakistan’s overall infrastructure needs have been estimated at US$500-600 billion. However, as opposed to this, last year’s PSDP allocations (2008/09) for infrastructure development approximately stood US$4-5 billion, and this year’s PSDP allocation through increased will also fall short. In view of resource limitations, the government has decided that many infrastructure projects, particularly those related to the transport sector, should be developed and implemented through public-private partnership under the umbrella of the Infrastructure Project Development Facility (IPDF) with support from PPP Infrastructure Cell of the Planning Commission. If appropriately structured, this approach can save Rs. 200-300 billion in PSDP expenditures.
While it is critically important to undertake projects in the PPP mode, it must be appreciated that this has implications for government’s capacity. Infrastructure projects have traditionally been funded by the public sector in Pakistan in the past. The government has some level of experience with PPPs through engagement in this mode with Independent Power Producers (IPPs) in the 1990s; PPPs have also been used in the past in the transport sector using the Build Operate Own, Build Operate Transfer, Rehabilitate Operate Own and Rehabilitate Operate Transfer modalities of engagement. However, in order to undertake major infrastructure projects in the PPP financing mode, transformation of the government’s capabilities and governance capacities is needed to plan, execute and implement.
The government must therefore plan to enhance its institutional competencies in the area.
Fortunately, some arrangements are already in place but need critical inputs, consolidation and or transformation. A PPP policy is in place at the federal level but legislation needs to be enacted. A draft PPP law has been pending action in Punjab for over five years and needs to be built upon further to develop a national legislative framework. Steps have been taken to develop transaction advisory capacity—IPDF has been created as a statuary entity under the Companies Ordinance (as a Section 42 Company) to provide technical oversight, help state agencies procure transaction advisors and technically support government agencies in processing and developing projects through the PPP route. It is important to ensure support to the organization from the highest level of government to enable it to serve its role. In order to ensure availability of long-term financing for PPPs, various financing arrangements—Viability Gap Fund, the Guarantee Fund, Infrastructure Project Finance Facility and Project Development—have been designed for some time now but have not been fully established. The PPP infrastructure Cell in the Planning Commission also needs to be supported and strengthened to plan and procure infrastructure with private sector investment. This arrangement with appropriate linkages and technical inputs from IPDF can be mandated to review all infrastructure projects for their viability regarding being channeled for private sector funding before going down the CDWP/ECNEC route in the Planning Commission. In many countries of the world, it actually has to be proved that infrastructure cannot be built with private sector investment before soliciting support for public financing such as is the case in South Africa and the highway sector in India.
An important caveat relates to capacity of the government to regulate. Infrastructure PPP’s are complex arrangements involving a range of stakeholders—public companies with official relationships with public institutions, transaction advisors that are procured by public agencies (IPDF in Pakistan’s case), operators, service purchasers, sponsors and contractors; there are various sources of cash flows and revenues and organizational objectives that have to be handled. In view of this diversity and complexity, the success of these arrangements depends upon fiscal and legal prudence of governments and their ability and transparency to build safeguards and share risk in a manner that is mutually beneficial, both to the public and private sectors—most importantly, to the population at large.
The other reason why the government needs to engage with the private sector is to enhance its capacity to deliver social services—health and education in particular. Pakistan has traditionally engaged in service delivery in a ‘welfare mode’ assuming that it bears the responsibility, both of financing as well as providing services but has under-resourced its infrastructure and service delivery arrangements; on the other hand, the regulatory environment has allowed burgeoning of the private sector in these areas with minimal—in some cases no—regulatory controls. As a result of this and the disparity in incentives in the public vis-à-vis the private sector, a characteristic abnormality has emerged; this manifests itself in public functionaries working in the private sector, and closed and underperforming health facilities and schools. This limits the ability of the government to target welfare to its citizens.
In order to address these challenges, action is required at several levels—in each, the role of the private sector is critical. In order to better manage public facilities, the government can rely on the private sector’s entrepreneurial talent either by contracting out management or applying private sector management principles and incentivize public sector delivery and in order to expand the outreach of services, the government can involve non-state providers of services. The decision by governments to act as payers for welfare services and only partly have responsibility for direct delivery of services has important consequences for shaping a social policy. However, the government will have to develop a new set of institutional norms and regulatory frameworks and change the way they have been doing business in the past in order to achieve this important goal.
The discussion on infrastructure development and sustainable macroeconomic growth and effective targeting of welfare service becomes more important and challenging today than it has ever been in the past in view of the unique pattern of conflict and violence that has emerged in our deeply polarized environment. The need to maximize synergies between the public and private sectors has therefore become an imperative. However, the results of such actions will only be as good as governments can make them. Governments with limited capacities cannot remedy their deficiencies by seeking to yoke the private sector on their own uncertain cart.
The author is the founding president of the NGO thinktank, Heartfile. E mail sania@heartfile.org
Institutionalizing Accountability?
The Holders of Public Offices (Accountability) Act 2009, which currently exists as a Bill and is to be introduced in the National Assembly, will perhaps be one of the most vital instruments of governance in Pakistan, over the coming years; its connotations and covenants defining responsibility for decisions and actions.
Given its importance, the relative lack of informed and constructive debate on the subject in civil society, political and analytical circles is indicative of a deep-seated phenomena in the country’s societal political culture—we tend to engage in trivialities of governance and remonstrate when the manifestations of poor governance are apparent, but when it comes to substantive structural issues, there is somehow limited proactive engagement to shape governance norms. This comment underscores the importance of seven points in relation to the proposed statue with the hope that the nation will pay greater attention to this subject.
First, it must be recognized that accountability as an aspect of governance is central to problems in the public and private worlds. As a result of limited accountability, poor governance, mismanagement, inefficiencies and malpractices have become pervasive in our systems. On the one hand, malpractices are exacerbated by poor management and lack of accountability whereas on the other, there are disincentives for strengthening management and mainstreaming mechanisms that compel accountability. Both these factors complement each other in a vicious circle. Limited accountability is the core determinant of this pattern.
Most of the issues that we see today, whether they are related to conflict and insurgency; issues of national security; ethnic and religious divides; Pakistan’s macroeconomic downturn; the looming issue of water security; the energy crisis; periodic shortages of commodities; poor performance of the social sector and of course, the overarching issue of extremism, exist because individuals and institutions, knowingly or inadvertently, have taken decisions and have opted for directions or have had deliberate inattention to oversight to the detriment of desired outcomes. If we continue to regard responsibility, answerability, blameworthiness, liability and other attributes of account-giving, the low level of importance they have been receiving, governance will further weaken and we will continue to face challenges, as we do presently.
Secondly, from an institutional perspective, the difference between an Accountability Commission and an Anticorruption Agency should be brought to bear. The writer has elaborated on the difference between the two in these columns on January 27, 2009. As per the stipulations of the proposed statute, the National Accountability Bureau (NAB) will be abolished and the Accountability Commission will be created in its stead. There was an expectation that since accountability (a mandate of the Accountability Commission) is a more overarching thread in governance, compared to anticorruption (the remit of NAB), the scope of the Accountability Commission would be broader than NAB. However, a review of the Bill reveals that jurisdiction of the Accountability Commission is more limited.
Thirdly, there are concerns that with promulgation of the proposed statute, a higher percentage of policy and decision makers and other offenders will be excluded from the ambit of accountability. The NAO is wide-ranging and covers a wider category of persons and offences; scope of the new law, on the other hand is relevant to holders of public offices only. Offences such as accumulation of assets beyond known sources of income, acquisition of unmarked properties and willful loan default stand excluded from the jurisdiction of the Accountability Commission under the Bill. There is a perception therefore that instead of strengthening, the proposed statute might weaken the process of accountability.
In the fourth place, a commission by connotation is a high level review/analytical/enquiry or executive/governing body. In the event of the former, it is time-bound and in the case of the latter, as is presently the case, it is on a more permanent basis. The idea in both is to fashion independence, objectivity, transparency and visibility in arrangements in view of the fact that commissions are usually created in a controversial and sensitive space; arrangements are additionally structured to guard against capture. Within this context, the proposed statute stipulates appointment of the Commission Chair for a non-renewable three year period and stipulates that both the treasury and opposition benches would be included in the consultation process for appointment of the Chair—these are positive steps indeed. However, the Bill does not mandate the creation of an independent participatory governance arrangement. An inquiry can be initialized only when a go ahead is given by the Chairman or a designate. Entrusting decision-making powers to one individual does not resonate with the spirit of a Commission; it creates space for maneuverability and capture by Pakistan’s elite-dominated and patronage-characterized political dispensation. We need to move away rather than reinvent the same factors, which were responsible for NAB’s partial stance in some cases. Impartial and participatory governance with civil society representation, an open disclosure policy and transparent terms of reference must be inherent to the structure of this Commission.
In the fifth place, the Bill does not clearly stipulate the legal status of the proposed Commission. Other existing commissions in the country have legally defined arrangements; the corporate regulator, Securities and Exchange Commission of Pakistan, is a ‘permanent’ statutory body. Similarly, the National Tariff Commission and the Competition Commission are also ‘permanent’ statutory bodies. All have a ‘perpetual existence’ in the form of a ‘body corporate’ with independent and distinct legal personality. The Bill does not however specifically discuss the legal status of the Accountability Commission in any detail.
In the sixth place, it must be brought to bear that federal and provincial government employees will fall within the purview of Federal Investigation Agency (FIA) and Anti-Corruption Establishments (ACE), respectively, after the enactment of the Bill. However the capacity of these institutions and their past history, which is indicative of politicization, needs to be factored into consideration. FIA’s failure to prosecute anyone above grade 19 in its entire history is often referred to in this regard. Institutions are additionally under-resourced and lack capacity. Considerable resourcing, market based incentives, capacity building and reorganization of these organizations would therefore be necessary.
Lastly, performance of the Accountability Commission must be contextualized to the broader context of the state’s capacity to mainstream accountability in governance arrangements. The broader anticorruption agenda should be revitalized in tandem. The National Anti Corruption Strategy (NACS), which has been dormant should be revived; the potential within certain implicit transparency building arrangements such as electronic procurement, electronic tracking of supply chains and the use of technology in public finance management—budgeting, accounting and auditing systems—should be fully leveraged and previous efforts to bridge weaknesses in the Freedom of Information Ordinance, 2002 should be resumed. Furthermore, institutions such as the Ombudsman’s office should be optimality strengthened for creating avenues of public redressal; strategic plans for incentivizing the civil service and promoting integrity therein, should be implemented; a level playing field should be promoted for businesses and help should be sought from the Competition Commission to weaken organized vested interests; moreover, a broad based agenda for systemic reform of governance, which can institutionalize accountability should be consolidated building further on many elements of that framework, which have been initialized piecemeal over the last 62 years.
Accountability is the unifying thread in governance. Enacting legislation and restructuring an institution should not be about change of name and an opportunity to structure space for maneuverability; instead it should be about substantively mainstreaming change that can bring value to strengthening governance, sustainably. Open and impartial oversight, independent governance, an open disclosure policy and a non-selective mandate are critical inputs in this regard and can make a well-resourced entity function effectively within this space.
The writer is the founding president of the NGO think-tank, Heartfile. E mail sania@heartfile.org
A Marshall Plan?
Published in The News International onApril 28, 2009:
The donor’s conference in Tokyo and the meeting convened by the Friends of Democratic Pakistan on its sidelines concluded on April 17 with a 5.28 Billion US$ pledge in economic assistance to Pakistan, congressional approvals permitting. A number of references have been made to this forthcoming package of assistance as being analogous to the post Second World War Marshall Plan, particularly in Pakistan, with the expectation that the outcomes will be likewise. It is important to understand that comparable impact is unlikely for a number of reasons.
First, the Marshall Plan was planned and implemented at a time when the United States had emerged as one of the greatest powers in the aftermath of the Second World War. At that time, the United States was affluent enough to play a key role in assisting with the rebuilding and reconstruction of Western Europe. The situation today is not comparable, as a result of the constraints imposed by the global financial crisis.
Secondly, the Cold War notwithstanding, Marshall aid was delivered in a post war era, in an environment where the huge job of reconstruction was to be executed; states in Western Europe thought that the best way of doing this was through a joint effort; in fact many moves towards unity took place during this time. Pakistan is still ravaged by conflict and many divides; even within this one country, the political and geo-strategic backdrop poses a number of impediments to the effective deployment of development assistance.
Thirdly, and most importantly, Marshall aid also had a sound macroeconomic rationale; aid was targeted in an environment where there was an increase in world demand for European products and where rapid technological advances were taking place. These factors coupled with assistance, which focused on rebuilding the industrial and agricultural base, helped Western European states to recover surprisingly quickly from the effects of the war. Today the global financial crisis and Pakistan’s own macroeconomic situation present a very different international and domestic context.
In the fourth place, and relevant to assistance in the space of the social sectors, it is important to recognize that Marshall aid was channeled against the backdrop of careful planning by several governments and in an environment of governance where systems and structures functioned and where legislative frameworks had already been created. The end of the Second World War had accelerated the demand for social change. In Britain for example, the Beveridge Report of 1942 had already provided a massive plan for welfare while the Butler (Education) Act of 1944 and the Family Welfare Allowance Act of 1945 had already been enacted. Governments and people in most of the Western European countries had shown a clear indication to move away from the pre-war complacency, which accepted squalor and high levels of unemployment as inevitable. The situation in Pakistan is not comparable in any way. High levels of poverty and lack of education are prevalent; the societal political culture—the lawyer’s movement notwithstanding—remains weak and consolidated frameworks to make equity and social justice a centre piece of public policy are yet to be developed, despite pronouncements in political party manifestos. In addition many structures that are necessary for aid to be effective suffer from weaknesses—it is well established that aid functions best in environments where structures, systems and frameworks are in place.
In the fifth place, Marshall Plan was implemented in an environment where the global normative and governance systems and a new global economic order were being concomitantly established. Conversely, today, the world is undergoing a profound transformation where a number of economic and political crises highlight the need for change in global systems, institutions and processes.
Lastly, size of the envelope must also be brought to bear. The level of committed assistance is far from adequate, as has also been publicly acknowledged by Ambassador Holbrooke. The government of Pakistan and the development partners must therefore step back and develop a set of pragmatic expectations for the level of assistance envisaged to be in the pipeline, particularly within the remit of development. There are a set of measures that the development partners should undertake and another dimension of imperatives the government should seriously consider. While doing so, it is important to bear in mind that aid is not the answer to our issues; that the problem lies at the level of laws, regulations, practices, mindsets and overall state functioning and that it will take political resolve and astute technical ability to overcome these constraints. Despite these limitations, aid has the potential to impact policies, governance structures and instruments in Pakistan, not by virtue of its size but because of limited capacity within the state system, which inadvertently makes room for policies to be donor driven and because of the conditionalities it can stipulate as a pre-condition for funding. This potential to catalyze change can be positively harnessed.
Development assistance in Pakistan has traditionally been allocated on the premise that it should be able to achieve the largest possible reduction in poverty. However, it must be recognized that these endpoints cannot be achieved without effective governance. Therefore, a core priority area for allocation of development monies should be to further accountability and transparency in government systems and bridge the key governance shortfalls through sectoral reform. Such choices can have a more lasting and sustainable impact compared to development assistance that sets up projects in ideal donor-resourced conditions, which subsequently cannot be up scaled because the core limitations in the functioning environment remain unchanged. In Africa much of the recent discussion on increasing development assistance has been in the context of a ‘compact’ particularly in the health sector within the rubric of the International Health Partnership, where aid from donors is being matched with increased attention to good governance by recipient countries. Such benchmarks can bring value in environments such as ours as well. Donors must also carefully explore the impact of integrating their foreign policy and development objectives in Pakistan’s complex socio economic environment and learn to benefit from democratic influences such as broad-based consensus driven planning outside conventional channels in shaping strategic priority goals. A stronger emphasis on streamlining Pakistan’s aid architecture, a more focused approach to maximizing synergies between partners and efforts to curb the costs of managing and delivering aid should also be a priority.
Additionally, the issue of fungibility of aid, which implies that governments may divert domestic resources to other uses given the presence of donor aid in a sector, and therefore, experience difficulties in reallocating resources to these priority areas, once donor assistance is not available, also deserves close attention.
The Government of Pakistan must look at this additional envelope of assistance as an opportunity to systematically strengthen country systems. The importance of a multi-partisan and broad-based stakeholder consensus on the Agenda for Reform has been reiterated in these columns on April 11; concomitantly, donors and the Government of Pakistan must also invest in domestic policy leadership. Without focusing attention on these central systemic issues, which continue to impede the greater impact of development assistance and overall state functioning, not much will be achieved in the long term.
It is hoped that in this environment where there are strong geo-strategic and security motivations for much of the aid coming to Pakistan, the rich countries will also review their broader development footprint and in addition to committing traditional bilateral and multilateral assistance will also assist in wiping out external indebtedness and assist with mainstreaming a more conducive framework for trade—both of these factors can have a more sustainable impact on development, welfare and Pakistan’s proactive and peaceful role in a globalized world.
The author is the founding president of the health sector NGO think-tank, Heartfile. E mail sania@heartfile.org
The White Paper and the question of aid effectiveness
Published in The News International on April 11, 2009:
The White House has recently released a White Paper on U.S. policy to Afghanistan and Pakistan, articulating a number of geo-political and development imperatives for the region. This comment will focus only on the dimension related to development assistance within the contemporary realm of aid effectiveness.
The US policy paper outlines a strategy centered on stepping up economic support to Pakistan; the importance of this has also been reiterated by President Obama’s three-pronged call for increasing development assistance for the country in his speech on March 27, 2009 and is evidenced by support signaled for the bipartisan Kerry-Lugar Bill and the Cantwell-Hollen-Hoekstra Bills and endorsement of support for Pakistan to the ‘Friends of Pakistan’ who are scheduled to meet in Japan later this month.
The policy statement has made some bold and honest admissions. For one, it has recognized that aid has remained “Ill-organized and significantly under-resourced in some areas [and that] a large portion of development assistance ends up being spent on international consultants and overhead, and virtually no impact assessments have yet been done on our assistance programs”. Recognition of these constraints can be helpful in working towards the intended impact of bilateral assistance in future. However, the forthcoming increase in assistance raises the question of the extent to which aid can be effective in achieving intended outcomes in an environment where inefficiencies are endemic. Review of development projects in Pakistan raises many concerns about the robustness of processes of the state that are meant to translate funding and other resource inputs into desired endpoints.
A historical perspective of global efforts initialized by development agencies to address the issue of aid effectiveness in environments such as ours can help put things in perspective.
Over the years, donors have rallied around a number of approaches centered on harmonizing and coordinating aid and pooling aid in support of a particular strategy led by governments; these approaches have partly been aimed at strengthening country systems and in part, aimed at minimizing duplication and high transaction costs of multiple donor inputs. Attempts by multilateral agencies to promote institutionalization of Sector Investment Programs, Sector-wide Approaches and Comprehensive Development Frameworks in developing countries have been part of this approach. Although many of these frameworks have not been adopted in Pakistan, per se, their principles were capitalized in the Social Action Program, which was implemented in Pakistan from 1992-1996 and more recently in the tendency to give aid ‘on-budget’ in alignment with the Medium Term Development Framework and the Poverty Reduction Strategy Paper.
Beginning in 2002, the aid effectiveness debate gained momentum with a series of consensus statements—Monterrey Consensus 2002, Rome Declaration 2003 and the Marrakech Memorandum 2004; these culminated in the Paris Declaration on Aid Effectiveness in 2005, a high level commitment to using aid effectively and was followed by the Accra Agenda for Action in 2008 to engage donors and developing countries in a new paradigm of aid as a partnership in order to achieve the MDGs.
The principles and corresponding targets of the Paris Declaration, centered on ownership, alignment, harmonization, managing for results and mutual accountability aim to strengthen country systems, capacity and leadership, synergize donor operations and harmonize, align and manage aid for results with a set of monitorable actions and indicators. The U.S White Paper strategy echoes many of these principles, particularly by signaling that assistance will be limited without the achievement of results.
The Organization for Economic Cooperation and Development (OECD) has conducted two rounds of monitoring, in 2006 and 2008, to measure the impact of the Paris Principles. For the second round of monitoring, findings reflect information provided by 55 developing countries in relation to USD 45 Billion of aid—nearly one half of all the aid delivered in 2007. Pakistan was not one of the countries surveyed; however, findings of the survey triangulated with existing information have been useful in developing a generic understanding of the impediments to aid effectiveness within developing countries. Conclusions of the OECD survey stated that “in order to change practices in international aid, there is the need to shape deep seated behaviors; these changes in the process of development and the nature of aid relationship require time focused attention and determined political will. It is not easy to change laws, regulations, practices and mindsets……”; in other words, there is a need to focus on the central systemic issues which continue to impede the greater impact of official development assistance. In many ways, the White Paper strategy seems to speak the same language in its call for ‘strengthening capacity of the country’ and admitting that there can be ‘no quick fixes’.
There are no disagreements about the need for deep-rooted systemic reform of governance in Pakistan. We all agree that transparency in governance is an imperative for achieving any public policy endpoint and that technocratic reform in the civil service domain and sectoral reform in areas such as public financial management, procurement and audit are critically needed; there is broad-based endorsement of the need to revamp the public management process and mainstream accountability and efficiency in state governance. All of us are passionate about addressing organized vested interest that promotes state capture, strengthening an independent judiciary and fostering civil society oversight, freedom of information, open media and avenues for seeking redress. If archives and documents of the Ministry of Finance and the Economic Affairs Division are analyzed, it becomes apparent that donors have assisted with institutionalizing systemic reform of every conceivable nature in the country. The problem is clearly not with initializing reform, but consolidating initiatives, ensuring effective deployment of pilot projects, sustaining initiatives and taking them to fruition.
It has become conventional for one government to initiate ‘reform’ and for the next to de-track or retract completely. There is almost no institutional memory or commitment to consolidate reform initiatives. It is almost a given for those in political roles to prioritize planning based on what is politically expedient and those in administrative roles not to confront them because of the fear of undue accountability; the institutional environment, is therefore, increasingly getting focused on short-term gains as opposed to outcomes and politicization of decision making, patronage, tolerance to circumventing procedures, systemic manipulation and graft has become a norm.
The importance of these impediments to systemic reform must be appreciated in aiming for economic stability for the country, welfare for its people and a positive proactive role of Pakistan in a globalized world. The current focus of the world on strengthening democracy in Pakistan is justified, but it must also be appreciated that democracy can only function if popular representation inculcates democratic behaviors of evidence-based decision making and consensus building and democratic values of equality and liberty; this can only be achievable with multi-faceted broad-based reform of the state.
A substantive discussion on the where, how, and why of systemic reform can help shape an agenda so that some quick wins in institutional restructuring can be realized. However, this must proceed with a multi-stakeholder ‘sign-up’ to an Agenda for Reform. An inclusive and participatory process should garner consensus of multi-partisan stakeholders, development partners, the establishment and civil society on a technically viable road map for reform and structure multi-stakeholder oversight of the process of its implementation to ensure that reform outlives administrations and is not held hostage to vested interest. This is a critical prerequisite to any substantive discussion on state reform.
Pakistan must make effective use of economic assistance in these financially constrained times; however, the objective should be to channel assistance to help strengthen country systems with a view to ultimately transition away from support and to promote debt forgiveness as a tool to free up resources.
The author is the founding president of the health sector NGO think-tank, Heartfile. E mail sania@heartfile.org
The fight against spurious drugs
Published in The News International on February 14, 2009:
The issue of spurious drugs has been in the spotlight for some time now beginning with the suo moto action by the Supreme Court in 2007 and the subsequent regulatory actions by the then government to the more recent creation of a sub-committee of the Senate’s Standing Committee on Interior.
The problem has elicited strong reactions by several governments—severe but fleeting and short-lived. The idea here is neither to analyze individual decisions nor to delve into their motivation but to explain that the presence of spurious drugs in the market is a manifestation of erosion of capacity to regulate and govern. Just as fever indicates systemic infection and changing temperatures herald climate change, the presence of spurious drugs signal the presence of deep-seated issues relating to oversight. The energy crises, episodic shortages of essential commodities such as sugar and wheat are also likewise a reflection either of absence of accountability of decision making or exploitation of regulatory prerogatives and ensuing graft at several levels—each of these is a core issue of governance and is therefore neither amenable to quick fixes nor fleeting coercive action. These issues demand an astute analysis of statutes and institutional implementing arrangements.
Analysis of the issue of spurious drugs highlights challenges at several levels most of which have emerged over time due to under-resourcing of regulatory institutions and weaknesses in mechanisms of accountability. The field force of inspectors who are meant to ensure that there is no mushrooming of backstreet manufacturing facilities and are mandated to exercise oversight to ensure quality at the retail level and in the distribution chain have no incentives to perform. Systems of compensation are inadequate for sustaining appropriate livelihood as a result of which institutionalized collusion has become a way of working and is almost regarded as a norm. As a result, harmful spurious products get manufactured and find their way into markets; these are detrimental in many ways. Sick and poor patients suffer further because they don’t get better despite out-of-pocket costs of treatment. The official economy gets hurt because spurious drugs contribute to the growth of the black economy and bonafide businesses get affected because of infringements on their legitimate profit-making prerogatives. Lack of separation between policy-making and regulation also create an environment for collusion.
These systemic issues highlight the importance of mutually reinforcing interventions at several levels in order to overhaul regulation and strengthen governance. They call for a review of statutes to analyze where loopholes exist and underscore the need to take stock of problems in implementing standards and ensuring distribution chain security. All this requires technical and administrative capacity and transparency in our systems of governance. A number of steps need to be taken in this connection.
First, there is the need to quantify the actual magnitude of spurious drugs. These do not just include true spurious and adulterated medicines but also include counterfeit. The Ministry of Health’s official reporting of the prevalence of spurious drugs is 0.4% based on the results of a nationally representative survey. The Government of Punjab has recently reported a prevalence of 15% based on a smaller sample size, whereas earlier, a northern countries’ Trade Office alleged significantly higher levels. In view of this conflicting evidence, the first priority should be to document the exact magnitude through an independent third party evaluation. Secondly, there is the need to addressed weaknesses of the Drug Act of 1976. The Act has strong quality of medicine related covenants, it’s other weaknesses notwithstanding. However, some of its rules are exploitable particularly provincial rules related to warranty of purchase; these have a direct relationship with inadvertently facilitating spurious drugs.
The most critical weakness in the law with reference to spurious medicines relates to its limited scope, given that herbal, nutritional and traditional medicines are not within its ambit. The currently in force Yunani, Ayurvedic and Homeopathic Practitioners Act 1965, under which traditional and herbal medicine is dealt with in Pakistan, does not provide for regulating products. This means that ‘medicines’ prescribed by 130,000 registered practitioners of traditional medicine are outside of any regulatory framework. This creates a major distortion as most of the spurious allopathic medicines are marketed under the herbal medicine cover. The Tibb-e-Unani, Ayurvedic, Homeopathic, Herbal and other Non-Allopathic Drugs Act, 2002 has been in the pipeline for over 5 years now and needs promulgation as a starting point to address this critical weakness.
The third regulatory dimension relates to the several institutional regulatory arrangements, which are currently in place to ensure quality of medicines. At the governance, oversight and normative level, the Central Licensing Board, Drug Regulatory Board and the Drug Appellate Board exist at the federal level and Quality Control Boards have been established at the provincial level. Each of these has a dedicated mandate. The problem is at the level of implementation; part of this stems from mandating the same agencies in policy making, regulatory and implementing roles, which creates space for maneuverability. At the federal level, creation of the Drug Regulatory Authority, which was approved in 2005, was envisaged as a mitigate against this by separating functions and entrusting regulation to an independent agency. However, work on that has not been forthcoming. It must be recognized that independent regulation has its own problems in an environment such as ours as it can fall prey to capture. Pakistan therefore needs to determine locally-relevant solutions in order to make drug regulation more effective and transparent.
The other institutional regulatory arrangement includes the field force of drug inspectors, which are meant to ensure compliance with rules at several levels. Federal inspectors of manufacturing facilities can invoke manufacturing licenses and provincial drug inspectors are mandated to exercise vigilance at the retail level in order to ensure quality at retail outlets and in the distribution chain. These arrangements are fraught with many challenges, both quantitatively and qualitatively, as a result of which there is a unanimous consensus to have greater scrutiny and higher level of regulatory vigilance in these arrangements. Recently, the number of inspectors in the field has been increased from 144 to 250, but still remains inadequate. Additionally, as the systems of compensation are not at all adequate to sustain appropriate livelihood, malpractices are rampant. Reform to improve quality of medicines should address this issue as a priority by developing appropriate systems of remuneration, while at the same time enhancing accountability.
The third important institutional arrangement is the network of drug testing laboratories. Existing arrangements are inadequate and poorly resourced. The government needs to make appropriate investments as this forms the backbone of quality regulation. The government should also subject sale/resale of local and imported second hand machinery and raw material to greater vigilance in order to impose an implicit curb on backstreet production facilities.
The Ministry of Health should take apex associations of pharmaceutical companies into confidence and explore how best to secure the distribution chain and incentivize the commercial sector to invest in track and traceability technologies and packaging protecting programs; these can limit opportunities for spurious drugs to get into the market. The government should also develop independent evaluation arrangements for random batch reconciliation. Furthermore drug regulatory arrangements at the federal and provincial level should work in close collaboration with custom and other border control authorities to curb smuggling of counterfeit medicines. Lastly, it is important to broaden the scope of public awareness to include measures that the general public can take in order to protect themselves against purchase of spurious drugs. This is particularly important given that regulation cannot be strengthened overnight, even if there is a political will to do so.
The author is the founding president of the NGO think-tank, Heartfile. E mail: sania@heartfile.org
Restructuring and reforming NAB
Published in The News International on January 27, 2009:
The government is on its way to revamping the country’s accountability infrastructure and statutes. It is evident from a review of news postings in early January, that the National Accountability Bureau (NAB) will be replaced with an Independent Accountability Commission (IAC) with the antecedent repealing of the current National Accountability Ordinance, 1999 (NAO) and promulgation of the Holder of Public Offices Act, 2009 (HPOA). It is important to ensure that this is not just a switch of acronyms but a substantive institutional restructuring and realignment of statutes as a step towards fostering accountability and transparency within the country—a core attribute of good governance.
The news items in early January surprisingly generated very low level of interest from stakeholders in the political and governance arenas and the civil society, all of whom appear to hold institutional strengthening esteemed in rhetoric. It must be recognized however, that unless we actively and substantively engage in shaping institutional norms and structures, rhetorical commitments cannot come to fruition. It is therefore with a view to initiating a dialogue on the subject that some thoughts are being articulated herewith in relation to the envisaged institutional restructuring.
First of all, it is important to clearly conceptualize the mandate of the proposed commission and recognize that an accountability body, as is being envisaged herewith has a different though related mandate than an anti-corruption structure, which is what NAB represented. The connotation of an accountability commission is too broad and all-embracing. Accountability as a concept in ethics and as a key aspect of governance can relate to several attributes. Even if it is limited to the political dimension of accountability as the proposed commission envisages encompassing, it is not clear whether it is in the financial, moral, procedural or performance realms. Not all criminal acts are defined in the penal code; some procedural misconducts and moral tradeoff by holders of public offices and lack of performance cause more damage to the state and its interests than graft punishable under the penal code. The government therefore needs to define the scope of accountability with respect to the envisaged IAC if the remit is accountability and not just anti-corruption-related work.
The concept of an accountability commission is closely linked to truth and reconciliation commissions, the most pioneering example of which is South Africa’s Truth and Reconciliation Commission established by President Nelson Mandela after apartheid. This example was followed by many other countries around the world including most recently Bangladesh in the creation of its Truth and Accountability Commission in 2007. There are also many other variants of accountability commissions. One model centers on the implementation of conflict of interest laws and analysis of public disclosures given the importance of disclosure in fostering transparency. Many States in USA follow this model. Accountability commissions have also focused on democracy and corporate accountability as in the case of a privately funded Canadian commission and on legislative modernization as a means structuring accountability in a country as has recently been the case in Bulgaria. Within Pakistan, the much referred to Charter of Democracy also refers to the creation of a Truth and Reconciliation Commission in order to counter politically motivated accountability. There are therefore several niches for an accountability commission. If the intent of the Government of Pakistan is to develop a commission centered on accountability as a core theme, it should explore the best fit for Pakistan’s setting taking into account pressing priorities and indigenous needs.
However, on the other hand an anti-corruption commission or any other anti-corruption institutional structure such as NAB has a more specific function, which relates to investigative responsibilities and/or prosecutorial functions. Most of the well known anti-corruption commissions around the world such as Hong Kong’s Independent Commission Against Corruption (ICAC), the Independent Commission Against Corruption of New South Wales, the Malaysian Anti Corruption Commission and the Corrupt Practices Investigation Bureau (CPIB) of Singapore perform investigative functions whereas some such as the Malaysian commission also perform prosecutorial functions, as did NAB until recently.
Any attempt to restructure NAB therefore, has to come up with clear directions for the investigative and prosecutorial scopes of work of the new body. From what is publicly known about the proposed restructuring it appears that there has been a call for a separation of the two functions. Corruption related investigative work involving holders of public offices as defined in the government statement is envisaged to be entrusted to the new body and the same relevant to public servants and the private sector is meant to be brought under the jurisdiction of FIA whereas prosecutorial functions are being handed over to the regular legal and judicial systems. Here it is acknowledged that in principal, it is a good idea to separate investigative work from prosecutorial functions as it mitigates the possibility of bias and acts as barrier against political exploitation. However, there are two problems in this regard in Pakistan’s context and the direction being envisaged specifically. One relates to concerns regarding two different groups of citizens being dealt with under different institutional arrangements and possibly varied normative arrangements—holders of public offices vs. public servants and the private sector—and it needs to be ascertained if this approach is discriminatory in any way. The other reservation relates to the capacity and efficiency of FIA as an independent and impartial agency given the historical perspective. Challenges emanating from lack of reform within the judicial system is an across the board issue as well which may dampen the impact of any new arrangement.
The last and most critical attribute relates to independence. A Commission by spirit is a constitutional body whose independence must be guaranteed in the same way in which the independence of the judiciary is guaranteed under a constitution. In view of this, the government carefully needs to review the extent of value that a commission with reporting relationships with the Ministry of Law can bring to fostering accountability of parliamentarians, who by virtue of their mandate can exercise a significant influence over the ministry. It might be of relevance to note here that Article 36 of the United Nation’s Convention Against Corruption (UNCAC) to which Pakistan is a state party requires independence and autonomy to be ensured for any anti corruption and accountability authority and any attempt to subvert that, inadvertent as it may be, is tantamount to a deviation from that norm.
There are many ways of institutionalizing independence of an agency as sensitive and politically exploitable as the one under discussion. Successful examples around the world, some of which have already been alluded to, have ensured independence by structuring systems of oversight, which provide policy guidance and oversee operational and administrative matters. Many countries have solicited the participation of individuals of unquestionable integrity from different walks of life in participatory governance arrangements ensuring that the selection process is transparent and consensus-driven. However, most of the success stories represent examples from developed countries with systems of governance far superior compared to Pakistan. Therefore, the key challenge for Pakistan as it sets out to restructure and reform the National Accountability Bureau will not just be to ensure ‘independence’ in governance arrangements but also to minimize opportunities of capture of independent governance by vested interest groups. It is only then that we can make a solid contribution to strengthening an anti-corruption structure and take a positive step to towards promoting political responsibility, responsible governance and public accountability. The need to do so cannot be overemphasized at a time when making governance effective should be one of the utmost priorities in the wake of unprecedented array of challenges the country faces.
The author is the founding president of the NGO think-tank, Heartfile. E mail sania@heartfile.org
The Global Financial downturn—imperatives for the health sector.
Nishtar S. Pablos-Mendez A. The Global Financial downturn—imperatives for the health sector. Lancet 2009;373:124.
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Financial crisis, social unrest and reform
Published in The News International on January 05, 2009:
The December 22, 2008 issue of Newsweek featured an article on the downside of Chinese state reform. Entitled ‘Why China is too scared to spend’, the article drew attention to the weaknesses created in the Chinese health system with the advent of market reforms in the 1980’s, which did away with the communes that funded the Chinese system of work-unit based welfare. The consequent negative impact on the Chinese social sector hit healthcare the worst, as bare foot doctors in villages and affordable hospitals in towns were replaced by privatized state enterprise. Currently, a majority of the population spends out-of-pocket to seek healthcare and as rightly pointed out in the article ‘a serious illness can wipe out a family’s savings’—a pattern labeled as catastrophic spending.
The word ‘catastrophic’ in the present context denotes an economically dire outcome for a family. This pattern of spending in health comes to the spotlight in view of the recent financial crisis because of its implications for spending patterns, as Chinese families, unprotected in terms of their health needs being financed, save chunks of their income in anticipation of the need to spend in the event of a health-related eventuality. This behavior is an impediment to spending and reduced spending in today’s environment is not desirable, given that one of the key strategies to address the current financial crisis is boosting consumption, not cutting it. As a result of this consideration, it is being recognized in China that a better healthcare system may be an impetus for domestic spending and increase in employment in addition to offsetting the social un-rest that can be a feared consequence of the present financial crisis.
Not all of these considerations apply in Pakistan’s context. The global financial downturn is not likely to impact Pakistan to the extent as it has in China and the more integrated markets of East Asia owing to the lack of full integration of Pakistan’s financial markets with international markets; additionally, the level of disposable incomes is comparatively much lower than in China. Notwithstanding, are important reasons for drawing this analogy not just for the health sector but for the broader construct of social policy in Pakistan.
First, a vast majority of Pakistan’s population runs the risk of spending catastrophically. According to a survey conducted by the Planning Commission of Pakistan prior to the development of the Social Protection Strategy of Pakistan, 2005, nearly two-thirds of low-income households reported that they had been affected by one or more shocks at some point in the last three years. Secondly, there is a high likelihood that slowing of economic growth in Pakistan—though for reasons other than in China—coupled with many other domestic issues will worsen the existing social unrest in the country. Both these considerations create an imperative for the state to enhance its capability to target social services to its population.
At this point, let us be reminded of our poor social sector indicators even independent of the present crises. Let us recall that we are off track in meeting the MDG’s and many other organically stipulated targets. Pakistan compares poorly in its social sector indicators in many areas with countries that have similar levels of per capita income and overarching economic development. In the health sector, data from the largest household survey ever conducted in Pakistan—the Pakistan Demographic Health Survey released in 2008—is a stark reminder of the stalling progress and failure to achieve certain straightforward endpoints such as immunization outcomes despite the availability of ample resources and political will on part of successive governments. We now have to accept that the capacity of our systems to deliver has been seriously eroded overtime and that unless deep-rooted systemic reform of the service delivery system and its governance arrangements is undertaken holistically, not much will change. The realization is sobering at a time when social unrest as a consequence of a number of domestic economic and political and external factors is envisaged to escalate to unprecedented levels. Reform of the social sector, therefore, becomes an imperative in today’s environment.
It often takes some sort of political or economic shock or a drastic change at the level of the state to begin a reform process. There have been many such shocks in Pakistan in the recent past. The earthquake of 2005 was the most notable—a time when the feeling of national solidarity was most palpable. Ongoing conflict, ethnic and religious divides and mayhem, the recent commodity crisis, and the domestic economic downturn are glaring examples of other recent shocks. However, none of these has galvanized unity amongst the political stakeholders about the directions of a reform process in an attempt to sustainably impact the lives of the disadvantaged; instead, attention has remained focused on the power interplay of partisan politics.
Let me at this point acknowledge that Governments in the past and present have developed several individual programs aimed at social protection and welfare. However, individual programs have their limitations in impacting outcomes and program-by-program fixes have inadvertently led to a whole series of uncoordinated, duplicative and sometimes conflicting initiatives housed in various ministries and departments at the federal, provincial and district levels.
A key prerequisite for a successful social policy reform in Pakistan’s environment entails introducing a set of interdependent and mutually supporting interventions. Developing an agenda for such a reform requires a coordinated analysis and revision of the social sector system as a whole, as a starting point. It would require both technical as well as political consensus. Whilst the former can be easily achieved with some level of creativity, commitment and skill, the latter is more problematic. Reform in any sector is a profoundly political process in a range of domains and institutions and involves many actors and processes. It has to be based on an explicit understanding of the changes needed at the level of institutional structures, human resource, policy, and regulatory and legislative domains; therefore in order for it to be successful not only does it have to be holistic, more importantly it must be sustained overtime. It is here that a critical bottleneck lies. Pakistan has a longstanding history of initiating reforms, reform-like initiatives and attempts with the potential to transform. However, every time with the change of government, previous initiatives are disregarded and planning starts de novo. There is no institutional mechanism or institutional memory to build further on initiatives in the pipeline and seek evidence for up-scaling impartially. Institutional decisions are determined by political expediency and political benefaction or are driven by vested interest. This is not to say that there is any dearth of committed individuals within the system—on the contrary. However, those with the understanding and the ability often do not have the clout or voice to ensure that the right decisions are upheld. If the present trend continues, we can never hope to reform structures of the state and instruments of governance and the present mayhem in the social sectors will continue to play havoc with the lives of the poor, as it has.
A plausible way forward is for all political stakeholders—the government, opposition, civil society players and religious community—to sign up to a multi-partisan vision and roadmap for a reform agenda that is technically and politically feasible and for every incoming government to abide by the consensus-driven plan. Reform is a mark of politically mature democracies and must outlive administrations. It is about time that we moved to a more substantive understanding of what democracy is all about and realize that in order for it to be successful it must strive to be true to social justice, which is one of its core values.
The writer is the founding president of the NGO think-tank, Heartfile (sania@heartfile.org)
Global crises—imperatives for a just social order
Published in The News International on December 14, 2008:
There is an apprehension within the development circles that the economic impact emanating from the crisis in international commodity markets and the affects of the global financial downturn coupled with constrained fiscal space in the country as a result of a number of factors inherent to Pakistan’s domestic situation is likely to hit development budgetary allocations hard, over the coming months. Such a situation is indeed plausible. While the lack of full integration of Pakistan’s financial markets with international markets, to some extent precludes the adverse impact getting imported into Pakistan as it has in the more integrated markets of East Asia, notwithstanding the synergistic effect of other factors will mean that the government will have fewer options to raise additional resources to support the social sector budget.
Pakistan will, from now on have to comply with the stipulations of the International Monetary Fund; these ingrain fiscal discipline and should not be used as an excuse to limit social sector expenditures. On the contrary these times require strengthening of interventions that support the vulnerable in terms of their social sector requirements. It is also not yet clear if development assistance from bilateral and multilateral sources upon which Pakistan has significant reliance particularly in the social sectors is going to be impacted and the level of scaling down over the next planning cycle, if that happens. Furthermore, over the last two years, there has been a move towards pushing development budgets ear-marked under the ‘revenue stream’ to the ‘public-private partnership domain’ with the assumption that the private sector will make necessary investment in infrastructure. Although this is generally a feasible approach, it is not likely to materialize any time soon given that a necessary prerequisite for attracting private sector’s investment in public private arrangements is an enabling environment and appropriate capacity to handle complex public private transactions—an area where Pakistan has yet to fully build its capacity.
Ironically, the financial downturn has hit at a time when difficulty in achieving the Millennium Development Goals, evidenced by the half way mark reviews (year 2008) underscore the need for greater investments in the social sector. Likewise, there is now a growing realization of the need to strengthen systems of delivery to achieve program targets at the global level, approaches which signify the importance of new investments to strengthen delivery systems. Against this backdrop, Pakistan is in the process of finalizing development instruments for its next planning cycle; the Poverty Reduction Strategy Paper-II, which has recently been placed in public domain for stakeholder review, has an ambitious agenda for a range of interventions for poverty reduction. The Medium Term Development Framework 2010-15 is also in the pipeline and inputs are solicited for an agenda setting exercise to recast its vision. Furthermore, since the new government has taken office earlier this year, many sectoral policies are undergoing review. All these strategic planning tools will need resources for implementation and it appears that our resource realities will not be able to support the plans, these instruments aspire to deliver. Within this financially constrained milieu, there are a number of imperatives for the government in terms of planning and ensuring financial allocations for a social policy agenda.
The first priority should be to synchronize planning and to review various national development strategies and associated operational frameworks (planning, budget, performance assessment frameworks) to develop a consolidated approach to the social sector. Efforts currently underway to restructure the Planning Commission—as outlined in a press release in the NEWS on November 20—can be used an entry point for synchronizing strategies and frameworks whereas the recently constituted Social Sector task force by the Planning Commission could review the current social sector agenda and offer independent advice on what the country should be aiming for and outline evidence in support of that.
The other priority is to ensure appropriate financing. Here several measures need to be pursued in tandem. First and foremost it is important to protect development budget from being squeezed and to protect against the cuts that were part of structural adjustments in the 1980s and 90s. ‘Every cloud has a silver lining’ as they say. Lessons from reviewing the course of events in the past show that such crises can actually galvanize political commitment for sustained social transformation because of their dire social impact. The Great Depression of 1929 and the subsequent evolution of social security in the United States and the establishment of the National Health Service in the United Kingdom after World War II are cases in point. The Government of Pakistan can use the present global financial crisis as an opportunity to broaden the base of social protection arrangements initiated as part of the recently established income support cash transfer program to include social protection measures for other areas where poor and vulnerable households run the risk of spending catastrophically as in the case of health. In addition to increase in the size of the envelope, a critical imperative for cash transfer schemes is to reduce opportunities for political benefaction and patronage in targeting and ensure transparency in management of resources.
Secondly, it is hoped that the ‘international community will do more and not less to help the world’s poorest people at its time of economic crises’ as a G 8 leader has recently stated. In today’s financially constrained environment, the government of Pakistan should make use of instruments of Debt forgiveness such as PRSP and debt swaps to free up fiscal space for the social sectors. The recent signing of the debt swap for EUR 40 million under the umbrella of the Debt2Health initiative of the Global Fund on AIDS, TB and Malaria by Germany, Pakistan and the Global Fund on November 30 in Doha can be an entry point to maximizing the role of debt forgiveness tools.
Thirdly, more than ever this is the time to recall the poor correlation between total spending and social sector outcomes and to reinforce the need to improve the returns on social sector spending. This can be done in many ways; reducing the impact of inefficiencies—at the level of allocation, which result in suboptimal allocation of available resources as well as at a technical level to reduce inefficiencies in relation to the monies invested in programs; by rationalizing transaction costs and better integrating programs and through better alignment of aid with national financing strategies as has been outlined in the Paris Declaration on Aid Effectiveness to which Pakistan is a signatory. In terms of returns on investments, the effect of corruption on compromising public investments in a highly constrained environment must be taken into account. Widespread patterns of regulatory corruption, outright graft in contracting and procurements, in-attention to accountability at various levels—performance, financial and political—cause more economic losses than are realized. Transparency promoting measures and systems reform are mutually synergistic. Pakistan must invest in strengthening its Public financial management, procurement and accountability systems and build fiduciary safeguards in this resource constrained time in order to use resources more effectively,
Finally, and most importantly it must be recognized that better planning and availability of resources can come to fruition only through effective governance. The writer has raised issues for consideration in this regard in these columns on August 3 and 17 and September 8, this year.
Pakistan’s policy makers must review their ability to target welfare services to their populations. This is not just a constitutional responsibility under Article 38(d) but also an imperative in view of Pakistan’s current geo-political situation and its unique pattern of conflict, and religious and ethnic divides, which make poor populations vulnerable to exploitation. This comment, with its focus on ‘planning and financing for the social sector’ will be followed by another comment next week on the construct of a social policy with some suggestions for a way forward.
The author is the founder present of the NGO thinktank, Heartfile. E mail: sania@heartfile.org
Scaling up research and learning for health systems: time to act.
Evans T, Nishtar S, Atun R, Etienne C. Scaling up research and learning for health systems: time to act. Lancet 2008;372(9649):1529-31.
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A new war – against polio
Published in The News International on October 23, 2008:
Pakistan’s security situation and the war on terror has become a top priority for the government. While the need to prioritize issues is understandable, attention to some other matters of the state on a war footing is also warranted. In many ways, the case of polio eradication is analogous to the war on terror given the international context within which it is being waged and the gains at stake. Since 1998, a Global Program on Polio Eradication spearheaded by WHO and involving many other agencies aimed at eradicating a disease from this planet for the second time in the world’s history since Small Pox eradication in 1979, has been ongoing. This initiative, involving 125 countries, more than 20 million health workers and vaccination of over 2 billion children worldwide has been able to achieve the polio eradication milestone in all except four countries of the world.
The premise is simple: immunization is a right of every child, vaccination is the most cost effective health intervention and a few drops of polio vaccine can prevent a crippling disease; theoretically, it appears as simple as that! But for Pakistan, which unfortunately is one of the four countries that have not achieved the eradication milestone, this has turned out to be a challenge. Today, polio in Pakistan is not just a ‘health issue’ but an insight into the way policies translate into implementation and a realization that health and other development outcomes are a multi-sectoral responsibility. This comment provides a snapshot of the determinants of failure and proposes a few next steps.
In terms of the determinants, first of all it must be recognized that there are factors beyond the control of the health sector. The security situation in FATA and NWFP, the ongoing fighting and consequent limited access of vaccinators to these areas; the tragic disinformation about polio vaccination as being harmful by misinformed religious leaders; the conspiratorial rumors about vaccine safety and the resulting refusal on part of parents to vaccinate children, even when the facility is being provided by the state at their door step and the extensive population movement across the Pak-Afghan border are the three key factors outside of the health sector. However, it must be recognized that new cases of polio, a resurgence of which has lately been picked up by Pakistan’s sensitive polio surveillance system are not solely arriving from areas that are fraught with issues of accessibility and refusal and import from Afghanistan but are occurring due to long-standing problems with existing immunization coverage.
Pakistan has had resources to immunize every single child since the early 1990s; however, the recently reported Pakistan Demographic and Health Survey, 2007 has reported that the percentage of fully immunized children in Pakistan currently stands at 47%; this is clearly unacceptable. Immunization is one of the simplest public health interventions and these outcome data indicate that there must be systemic flaws in our systems of health service delivery and their means of monitoring and mechanisms of accountability. Absenteeism in public facilities, shaving off hours by paramedical staff, the well institutionalized ways of pilfering commodities from the supply chain, collusion in monitoring records and lack of motivation to achieve targets are issues the health sector has long been grappling with. The critical role of these malpractices in undermining the effectiveness of well resourced initiatives backed by strong political commitment should become evident through the case of polio eradication.
Additionally, there are also problems specific to polio eradication as an initiative per se. The vaccine cold chain is critical to the potency of vaccine; with the currently on average 8 hours of load shedding, the question of how that is being maintained becomes relevant. Mobility of vaccinators is a prerequisite for ensuring coverage; with paucity of vehicles, volatility in prices of fuel and variable availability, and temptation to embezzle allowances at the field level, how is that being ensured? Diarrheal disease can interfere with the uptake of polio virus in a child’s intestine; to what extent can a polio program have control over that given that overarching issues of poor sanitation and high population density continue to prevail and result in frequent outbreaks of what gets labeled as ‘gastro’. Capable and committed EDOs of Health are critical to the success of this initiative; with rapid turn over, how can performance be ensured and how can accountability be institutionalized. Then there are conspiratorial theories of there being a vested interest at an administrative level to linger on with National Immunization Days—the key instrument of polio eradication—because of the incentives linked to them. All these factors interact and are responsible for failure to eradicate the disease in Pakistan. What are the implications? So long as a single child remains infected, children in all countries are at a risk of contracting polio!
What are our options to pursue the polio eradication goal? On the one hand, evidence based systemic reforms of the immunization program must be pursued. However, meanwhile other strategic war like measures aimed at eradication must be developed over the short term. Here we must recognize that despite the high level political commitment of several governments, two critical gaps remain—simply, some populations in Pakistan are not being reached and the issue of effective targeting in areas that are accessible, looms large. What therefore is an urgent imperative for the government of Pakistan to enable it to achieve the polio eradication goal?
The priority would be to recast the NIDs and aim for few Grand NIDs, where the entire organizational might of the government is put behind the shoulder to this wheel on a war footing. After all, China was able to eradicate polio only after three NIDs but with an effort that truly involved all actors of the state. The following measures would be important in this regard. First, the outreach drive in NIDs must go beyond traditional vaccinators under the umbrella of EDOs to involve actors that can truly deliver in catastrophic situations. The armed forces have traditionally been part of catastrophes, emergencies and devastations. If saving lives is part of their mandate constitutionally, and waging war a core responsibility, involvement in polio eradication appears fully justifiable. Such an approach will have many caveats relating to image and acceptability but can be addressed with careful planning. Second, the government has to commit to utilizing all its resources and prerogatives on a war footing to ensure a seamless supply chain over a few days; airlifting of vaccines, allowing access to areas on horseback, procurement of new cold chain equipment and possible imposition of curfews for the duration could be part of this approach. Third, through the creative use of quotes from the Quran we can link polio to the right to life and negotiate access in areas where refusal is an issue and solicit ceasefire for the days of the intervention—for all we know, this could be the path to peace and tranquility in the war riddled zones of FATA and NWFP.
Operation polio, as we should name this, will have to be based on a careful evidence-based strategic planning exercise to fashion these new tactics. Such a plan, which leverages all these unconventional channels for a health objective is ambitious and requires high level political commitment; in Pakistan’s current scenario, it appears that if we want to achieve the eradication objective—as we must—then there aren’t many other options available. By winning this war, we can not only provide the much needed boost to our population’s morale but also stand solid in a globalized world by having made a meaningful contribution to global health.
The author is the founder present of the NGO thinktank, Heartfile. E mail: sania@heartfile.org
NAB and related governance issues
Published in The News International on September 30, 2008:
The government has decided to repeal the National Accountability Ordinance 1999, and has drafted a bill to legislate for an alternative accountability mechanism; with the promulgation of these statutes, the National Accountability Bureau (NAB), Pakistan’s apex agency mandated in an anti-corruption role will be replaced by an alternative accountability body. The draft bill is not in the public domain and cannot be commented upon and the shortcomings of the earlier Ordinance have not been publicly debated. Notwithstanding, an opinion is offered as this clearly, can be an opportunity to address current weaknesses in the country’s anti corruption institutional mechanisms and legal system.
Within this context, the objective of this opinion is threefold: first to contextualize NAB’s niche in the broader remit of institutional arrangements that are of relevance of anti corruption reform. Secondly, to comment on the need for other statutes that need to be promulgated in tandem with an accountability law. Thirdly and most importantly, to draw attention to other broader measures and sectoral approaches in public sector reform, which have a bearing on addressing corruption and to outline the role of other actors in this regard.
First, with reference to institutional arrangements, NAB is primarily mandated in an investigative anti-corruption role, as will the new agency be. In any comprehensive anti corruption framework however, this should be supplemented by institutional pathways for public redressal and mechanisms for institutional oversight. In Pakistan’s landscape, the former is the Ombudsman’s office and the latter are the Public Accounts Committee of the Parliament and the Office of the Auditor General. It is logical therefore that alongside measures to reform the investigative arm, weaknesses in other key institutions are also analyzed and addressed in tandem, if the intent is to fight corruption. In this regard, election of the leader of opposition as Chairman of the Public Accounts Committee on September 19 is a positive step; it is hoped that it will lead to impartial outcomes; it is also hoped that other gaps in institutional arrangements such as the Ombudsman’s lack of mandate to take up corruption cases will also be carefully reviewed.
As far as the new investigative agency is concerned, in order for it to carve out a role for itself as an agency, which brings public value, structural and substantive efforts are needed that go beyond change of name, and prosecutorial reporting relationships to mechanisms that make governance of the agency transparent, impartial, independent and free from the danger of being maneuvered. International standards as outlined in Article 36 of the United Nations Convention Against Corruption (UNCAC) require necessary independence and autonomy to be ensured for any anti corruption authority so that the agency can carry out its functions effectively and be free from undue pressure. In this regard, the statutory status of the institution, appointments and dismissal procedures for directors and other senior posts, independence of investigation and possibility of direct communication with the mass media assume importance. Without enabling an autonomous and independent status, any change is not going to be effective and it is hoped that as the new bill evolves, it will be sensitive to these considerations. In addition, it is also hoped that the new law also pays due attention to setting norms and standards from ethical, moral, procedural and intellectual aspects within the ambit of anti-corruption reform.
Secondly, whereas the focus on the National Accountability Ordinance (NAO) as a legal basis to reform the apex anti corruption body in the country is justified, there is also the need to review the broader legislative agenda for transparency promoting reform. Attention is needed to improve criminal codes and review laws relevant to the judiciary itself. Pakistan does not have laws relevant to white collar economic sabotage and explicit whistle blower protection laws; the latter are needed to enable and encourage citizens to come forward to law enforcing agencies to report on corruption incidences. In the same vein, freedom of information (FOI) statutes are critical; here it must be clarified that FOI statutes are not about media freedom, but have to do with access to information and disclosure which can enable public discourse in larger national interest on issues of governance. The present government intents to repeal/amend the FOI statutes, 2002; it is hoped that the new law will bring greater value to disclosure and access to information.
Thirdly, it is important to view anti corruption reform in its broader scope. Historically speaking, Pakistan adopted the punitive, investigative and sanctions-oriented approach to corruption since the inception of anti-corruption work many decades ago. However, earlier police like investigative agencies fell prey to corruption themselves and NAB created later was, perhaps inadvertently, but inherently directed against political opponents in some cases; additionally, despite its successes in asset recovery, it was perceived by some as pursuing a controversial agenda with reference to plea bargains. The objective of new statutes, in addition to the previously mentioned attributes, should therefore be to remedy these weaknesses and place greater emphasis on prevention, awareness creation, technical coordination and implicit transparency promoting measures.
Alongside these measures it is important to view anti corruption reform in a holistic context of state/public sector reform. Such a systemic reform can have many sectoral characteristics involving many actors within the public and private sectors; it can include public financial management, civil service reform, reform of the judiciary and the legal system, decentralization of government, reform of public procurement and contracting, strengthening audit systems and revenue collection, and other related areas. Reform of the judiciary is particularly relevant in this case, given that under the new statutes, NAB courts will be placed under high courts.
In most areas, some work is already in the pipeline in Pakistan, supported by several international official development agencies. Projects to Improve Financial Reporting and Auditing (PIFRA), work of the National Commission of Government Reform (NCGR), the Access to Justice project of Asian Development Bank, the Devolution of Government initiative of 2001, the e-Governance initiative, automation of CBR, electronic procurement reforms and establishment of the Public Procurement Regulatory Authority, reform initiatives of Public Service Commissions, strengthening of regulatory agencies, examples of market harnessing means of regulation in the social sector, etc., are some of the examples of systemic reform of governance in various stages of implementation and in some cases, they have stalled.
It is therefore important to develop a broad-based national agenda for systemic reform incorporating all these and other relevant aspects of state reform with the consensus of all the political actors, the civil society, development partners and of course the government. Every political party should sign up to owning the agenda during their envisaged term in office so that reform is sustained overtime regardless of who assumes office. This should be one of our medium to long term priorities.
However in the short term, the immediate item on the agenda is modification of existing statutes; here as a first step, shortcomings of the existing NAO 1999 should be identified; as a next step it should be ensured that the new law is fully compliant with the covenants of UNCAC, which Pakistan is a signatory to and has ratified on August 31, 2007.
It is in the interest of any government to tackle the menace of corruption not only because it retards economic and social development but also because it is one of the leading causes of government instability and can attack the foundation of democratic institutions by distorting electoral processes and perverting the rule of law. Without a strategic approach to transparency building reforms, the social and economic costs of corruption will keep escalating and will continue to take an irreparable toll in an environment that is crippled with the weight of the many existing international and domestic crises.
The author is the Founder President of the NGO thinktank, Heartfile. E mail sania@heartfile.org
Democracy and governance – upstream determinants
Published in The News International on September 08, 2008:
With the conclusion of presidential elections, the power configuration within the state has been defined. ‘Majority rule’ or ‘a few ruling with the consent of many’, described by the Greeks centuries ago, as a characteristic feature of democracy has been established within Pakistan and constitutional stipulations as articulated in Part III of the Constitution with reference to its Chapters on the President and Majlis-e-Shoora (Parliament) have been adhered to. At this stage, let us be reminded that while democracy, as understood conventionally is a necessary condition for a good government, it is certainly not a sufficient condition. This comment is intended to objectively draw attention to other characteristics that need to be woven into the equation in order to enable democratically elected governments to successfully navigate the ship of the state.
Democracy is not just about ‘majority rule’; it is an amalgamation of many attributes. First, it is a set of institutional arrangements or constitutional devices; by this measure, Pakistan has achieved a democratic milestone. However, there are other institutional democratic practices and doctrines of government, which merit close attention. Under parliamentary democracy and the Constitution of Pakistan (Part III, Chapter 3), government is meant to be exercised by delegation to the executive but it is also meant to be subject to ongoing review, checks and balances by the Parliament. In this regard, constitutional restraints upon the elected government assume great importance. It is in the interest of the government to consciously inculcate objective checks and balances in its institutional norms as majority rule without checks is likely to be abused, as has been witnessed in the past.
Secondly, democracy is also about individual behavior; practices of openness and collective deliberations, consensus-building, participation and evidence-based decision-making are attributes of individual behavior highly valued in public offices and ones that must be well institutionalized. The third and most important feature is a set of democratic values. Democracy as a value is closely related to liberty, equality, freedom and rights. Governments need to be democratic not just in institutional but also in a social sense with attention to individual liberties, human rights, equitable economic progress and social justice.
It is relevant to note here that many attributes of democracy are deeply interlinked with principles of good governance. It is only when decision makers conform their behaviors with values common to both – fairness, transparency and accountability – that it becomes possible to achieve intended outcomes. It is here that a critical gap exists; in order to elaborate on that, an explanation is offered. In matters of the state, deliberations and practical interplay usually occurs at two levels – at the level of input and output. Exceptions notwithstanding, at the level of input, there are power struggles, disputes and individual and institutional rivalries characterizing politics and a preoccupation to get into public roles. At the level of output, on the other hand, the dismal economic and social state is a constant focus of attention. There is something in between these two, which often does not merit the attention it deserves. The critical link is governance. Allow me to draw an analogy to help illustrate this point. Brick and mortar and expensive fittings as an input, with the expectation that hot and cold running water will be delivered in a washroom as an output, can only be achieved if functioning pipes are in place. The functioning pipes of the state are its institutional fabric of governance and systems of which institutional democratic behavior is a part. Just as there is no hot or cold water when pipes get choked, similarly when governance and institutions are ineffective, state institutions cannot deliver, regardless of who is at the helm of power and irrespective of the nobility of intentions.
If a review of Cabinet and ministerial decisions over the last 61 years is conducted, there will be no dearth of standalone schemes, programs, packages and relief measures for the social sector, infrastructure building, economic revival, etc.; problems with effective deployment and targeting have always been ubiquitous and for the simple reason that principles good governance and desired institutional democratic behavior have not been adhered to in their true spirit.
There is irrefutable evidence in support of good governance as being essential to foster the environment for economic growth and being central to improving the lives of people. It is well established that good governance contributes to higher per capita incomes and higher standards of living, better health status, lower infant mortality rates, higher literacy, and poverty eradication in populations. ‘Governance’ and not just the ‘formation of a Government’ should therefore become the reference point and a defining thematic priority in organizing the affairs of the state in Pakistan.
It must be recognized here that good governance is all about fairness, transparency and accountability in policy formulation and its implementation. Many a times those at the helm of affairs violate these principles – often inadvertently. When authority is misused, procedures are circumvented, laws are manipulated, nepotism and cronyism is furthered, state capture by vested interest groups is silently enabled, when a blind eye is turned to regulatory collusion or administrative malpractices, or when political patronage becomes the norm, key principles of governance and democratic values are violated. With every action, the state’s institutional fabric is weakened.
If governance is every public actor’s responsibility as is outlined above, why then the reference to ‘upstream determinants’ in the title of this opinion? This is for the simple reason that the choked pipes of governance can only be opened through plumbing upstream; if the principles of neutrality, transparency, fairness and objectivity are fostered in the affairs of state at the highest level, their importance will automatically cascade to governance at lower levels; without this, it simply will not be the case. It is opportune particularly today to flag this as a priority.
So what can be the plausible next steps if there was a committed champion within the system? The first would be to take stock of where we stand objectively, dispassionately and apolitically. The author in an opinion in these columns entitled ‘Governance Empirics’ on August 3 stressed on the use of validated instruments to asses governance and concluded by recommending that the government convene an independent task force to ascertain current challenges and subsequently set benchmarks for their own performance.
The second critical imperative would be to mainstream transparency promoting reform. The writer in another opinion in these columns on March 18, 2008 outlined a set of four measures centered on i) reviving the national anti corruption strategy; ii) bridging gaps in institutional mechanisms relevant to anticorruption reform with reference to mechanisms of public redressal, oversight and investigative work; iii) institutionalizing integrity promoting measures in the public sector; and iv) mainstreaming implicit transparency building measures with reference to the use of technology and competitiveness as entry points. These and other analyses on the subject can be reviewed for implementation in a phased approach. Thirdly, reform of key institutions of governance, should be a priority building further on the many initiatives of the past 61 years.
The cost of inattention to reform at this level can be enormous given the country’s precarious economic, social and security considerations, which are compounded by a number of factors. Our unique pattern of conflict, violence and terrorism; our national milieu, which is rapidly getting divided on ethnic, religious, sociopolitical and foreign policy grounds; the vulnerability of our populations to exploitation and the ongoing and impending food and energy crises exacerbated by global factors, are to mention a few. Reform will be slow and painful and will require sustained commitment to be successful. Although this is not a case of quick visible political wins, good governance and holistic democracy has to be at the heart of the affairs of the state; without that we are in for very rough weather.
The author is the founder president of the health sector thinktank, Heartfile. sania@heartfile.org
Independence Day – an ode to governance
Published in The News International on August 17, 2008:
14th of August is as august as a day can get, both for Pakistanis who have witnessed the perils of partition and experienced the anguish of being in a subservient role as well as those of us born after independence; the latter can be attributed largely to ‘temporal depth’ – the characteristic understanding in nations of the past forming part of the present – and our collective consciousness, both of which we hope, will cascade to the next generation. Most of us would like to believe that the ‘nation’, as a territorial community and ‘patriotism’, as a commitment to the well being of our country, constitute an important aspect of our lives. However, other than periods of intense enthusiasm witnessed during the wars and the more recent sentiments of solidarity exhibited in the aftermath of the devastating October 2005 earthquake, we are often not clearly mindful of what truly constitutes the nation’s well being.
Allow me to illustrate that point further. As government entities at various levels, businesses, NGOs, civil society, politicians and citizens in general, we tend to focus on economic, social or political outcomes depending on who we are; however, in the process we tend to forget that the process attribute central to achieving end-points in each of these realms is governance. The public sector in general and various levels of government in particular, often feel that they have fulfilled that obligation with enunciation of polices and planning instruments, promulgation of statutes and by creating institutions. A range of Planning Commission instruments and sectoral policies, laws listed in chronological tables and indices of the Pakistan code and the plethora of state and quasi-state institutions as evidenced by the Federal Bureau of Statistics’ inventories are evidence of that. It must be appreciated however, that policies, laws and other instruments can only be implemented through effective governance; more importantly, the latter is also the means through which institutions can create an impact.
Here it is important to review the context in which the word governance is being used herewith. Governance operates in organizations of any size – from governments at several levels, businesses, corporations, NGOs, partnerships or for that matter any other purposeful activity. It can also have several connotations: corporate governance, global governance, national governance, local governance and so on. The context in which governance is being used in relation to Pakistan’s Independence Day is governance within government agencies at various levels of the government – federal, provincial and local, other state agencies and agencies mandated with a public role. The word limit on this opinion precludes a reference to specific issues of governance within the local government system, the basic premise of which is currently under debate; the subject will be addressed in a later opinion in these columns.
It is well established that good governance is critical for achieving socioeconomic development and poverty reduction; in addition, effective and transparent governance within public sector institutions can also shape business ethics and corporate governance, which can enable businesses and the private sector to play a more effective role in national development by providing a level playing field and building safeguards against capture by vested interest groups. Good public sector governance can additionally shape democratic ethos and ensure representative governments on the one hand and bring objectivity and impartiality to global governance and decision making on the other; the latter in particular is needed for peaceful and meaningful co-existence in a unipolar world – a consideration particularly relevant for Pakistan.
The primary responsibility of every government and state agency therefore is to conform its operations with desirable governance characteristics to ensure that governance is participatory, consensus-oriented, responsive, effective and efficient, equitable and inclusive and follows the rule of law. Every crisis observed in the country today can be attributed to a violation of one or the other of these eight attributes.
Every government starts off underscoring the need to reform governance and strengthen institutions; that lack of institutional robustness is a national predicament, has become a sine-qua-non of political rhetoric in Pakistan. However, we need to understand what it actually means to actualize this commitment in terms of setting directions, day-to-day decision making, and implementing decisions. Two attributes are critical in this respect. The first attribute includes transparency, consensus building and participation in decision making in order to avoid capture by vested interest groups whereas the second attribute relates to accountability of all the actors in public institutions at the political, performance and financial levels to ensure that oversight and regulatory functions are not exploited by the powerful and the elite.
In order to ensure institutionalization of these attributes, reform of governance is needed not just in the executive arm of the state as is conventionally envisaged, but the two other pillars of the state in addition to the political system. The government needs to build on efforts in the pipeline, initiatives of the establishment division, work of reform commissions and consolidate development partner efforts to reengineer business processes of the state, reform civil structures and move towards the desired functional separation of policy making, regulation and implementation functions of the government, which is critical to bringing transparency in public sector processes.
To wrap up recommendations on governance assuming that the onus of responsibility lies solely on governments would be simplistic. There are many actors in governance. The role of the media, lobbyists, political parties, NGOs and businesses in governance is well recognized; in Pakistan’s situation particularly in the local government realms, landlords, land mafias, religious groups and other factions also shape the societal political culture and hence influence governance. Part of this population occasionally engages in an ‘advocacy mode’ in relation to the affairs of the state as was witnessed during the recent judicial crisis. However in general, outside of the corridors of power, citizens generally do not take into account the impact of their actions or inaction on the state’s institutional fabric and quality of governance. The reality is quite otherwise. The role of citizens, communities and the private sector in impacting public sector governance becomes evident when tax payers collude with tax administration, when the private sector colludes with regulators in allocation of subsidies, licenses, quotas and price ceilings, when commercial interests bypass procedures in order to increase market shares and when the business community seeks to modify policy stipulations through statutory regulatory or executive orders to suit their interests. When contractors and suppliers are in cahoots with public sector procuring agencies, in the event of private suppliers not meeting expected standards, or in cases of state commodities getting diverted and pilfered with private sector accomplices, the role of the actors outside of the government in shaping governance is additionally evident. We often do not recognize that a seemingly innocuous ‘sifarish’ can strengthen the culture of patronage, that the occasional trivial bribe we pay would help strengthen administrative rent seeking, that the payment we make to get a free service would conflict with the principles of delivery of public good and mis-target state services or that a seemingly insignificant unethical financial practice would have negative consequence for the economy.
Let us recognize therefore, that most of the crises that we face today are the outcomes of weaknesses in governance. Let us also acknowledge that it is not just those in the corridors of powers but also those outside of it that can help shape and improve governance. Let the Independence Day, observed two days ago lend impetus to a resolve to address what really needs to be improved in order to address the crises that we continue to face on many fronts. Each of has to go beyond our comfort zones and over-the-tea-cup-living-room discussions of poor governance to play a small part, with the realization that collectively this would have a major impact.
The author is the founder president of the NGO health sector think tank Heartfile. E-mail: sania@heartfile.org
National trade policy 2008-09 – the trade-health interface
Published in The News International on August 09, 2008:
It is conventional for the commercial sector to assess and comment on the potential impact of a trade policy as was evidenced by the plethora of commentaries on the media subsequent to the enunciation of Pakistan’s National Trade Policy 2008/09, on the eve of July 18, 2008. The social sector seldom considers it within its remit to scrutinize possible impact of the course of action adopted on social outcomes nor does it create awareness about the need for trade policies to include elements relevant to their scope. However, the contemporary understanding of trade, which scopes beyond merchandise to also include services and human resources, is changing that notion and creates an imperative for the national trade policy to broaden its scope. The case of health is illustrated to demonstrate why and how this is so.
The World Trade Organization’s General Agreement on Trade and Services and majority of regional trade agreements allow countries to undertake commitments in trade and investments in health services if they so desire, in line with their own policy objectives. However, in the Uruguay round and in subsequent session negotiations, the lowest number of commitments by WTO members was in the health sector and not a single health negotiating proposal was advanced in the Doha development agenda. Despite this, cross border trade in health in countries such as Pakistan is burgeoning under the combined influence of a number of factors. In this regard, four channels of trade in services need to be taken into consideration while developing a trade policy.
First is the area of cross border supply of health services as a result of the 20th century information communication technology boom, which has created opportunities for business process outsourcing. Within the domain of health, Pakistan has become an option for low value off shore healthcare back office services like medical transcription, and billing due to low cost of labor. However, high value remote diagnostic and reporting services are limited due to the absence of regulatory frameworks and limited international marketing capacity of Pakistani companies – a gap the trade policy must address. Overall, the ‘outsource’ industry, has had a positive impact on employment generation; however, it does not add value to healthcare locally in the country, in terms of fostering improvements in quality through the spillover effect as has been observed in many other countries; it needs to be explored how that potential can be tapped. Additionally, on another note, it must be determined how Pakistan’s network connectivity, which has enabled development of the outsourcing industry, can be used to benefit geographically remote areas within the country through telemedicine.
The second mode of trade in health is consumption of health care services overseas. Many far eastern countries have leveraged the potential therein to improve their health systems, which then become an important source of foreign exchange and add to the multiplier effects of tourism related activities in the economy. This type of trade in services has taken an undesirable route in Pakistan, as in many other developing countries with burgeoning of kidney transplant tourism. In 2007, the Transplantation of Human Organs and Tissue Bill, 2007 was promulgated; however, since then the subject seems to have been relegated to the background; it is over simplistic to infer that the state’s job in curbing the illicit kidney trade comes to fruition with the promulgation of these statutes; impediments to the implementation of the law also need to be addressed.
Here it must also be recognized that medical tourism has limited potential in Pakistan for a number of reasons. The success of medical tourism depends on many factors: high degree of sophistication of indigenous health systems, high quality of health care at low costs, an expatriate-friendly environment and a well developed tourist industry, being the foremost. Based on these criteria it is clear that the medical tourism industry would not have an emerging trend in Pakistan at least in the short to medium term. It is therefore important that public resources earmarked for health should not be used to promote medical tourism at the cost of essential health services as there is little benefit to serving the equity objective in health except indirectly through improvements in quality.
The third mode of trade is commercial presence, of a foreign service provider in a host country for the purpose of supplying health related services. Pakistan is the sixth most populous country in the world and a large market. If the country’s overarching investment climate permits, investments in the healthcare sector from off shore sources, are likely to increase due to the overarching policies of liberalizing services traditionally in the public domain, which governments have pursued over the last ten years. While this approach has its benefits in terms of upgrading healthcare infrastructure, facilitating employment generation and providing a broad area of specialized medical services, it can also create inequalities by creating a two-tiered health system with high quality care being supplied to the affluent. The trade policy should therefore, articulate its position in this respect. Additionally, it should also outline the government’s principles for offering subsidies to foreign service providers in view of the concerns that that this can divert resources from health interventions that can be more equitable in their outlook.
The fourth mode in trade in health services relates to migration/movement of health professionals, out of the country. Such movement can exacerbate existing health workforce shortages as is particularly being observed in the case of nurses, paramedics, and public health professionals in Pakistan. The current doctor-nurse ratio has been 2.7:1 for some time as opposed to the recommended doctor to nurse ratio of 1:4; despite this, more than 1,800 nurses trained at state expense have moved out of the country over the last five years. A trade policy must therefore articulate the country’s policy position on trade of health related human resource. Clearly the priority should be to meet health workforce needs of the country through appropriate retention arrangements as opposed to a focus on export on the premise that the latter generates foreign remittances.
Another consideration of relevance to the trade-health interface is the WTO agreement on Trade Related Intellectual Property Rights (TRIPS); Pakistan is a signatory to the agreement and has promulgated the Patents Ordinance 2000 to comply with its requirements. Given that these stipulations have the potential to create barriers to access to medicines, a national trade policy should outline how the country envisages using flexibilities granted by the Doha Declaration on TRIPS agreement and Public Health (2001), namely compulsory licensing, parallel imports and bolar exemptions (which the word limit on this opinion preclude explaining) to overcome these barriers in the interest of public health. Under the National Trade Policy 2008/09, an intent has been signaled to develop plans for establishing a bioequivalence laboratory. Although this interest stems largely from the focus on export of generic drugs, with which trade in health is closely identified with in Pakistan, it must be recognized that it’s more important functions relate to quality improvement of medicines and institutionally helping implement flexibilities grated under the Doha Declaration on Public Health.
In summary therefore, it is important to see trade in a holistic but an equitable manner and broaden its scope from commodities to the entire value chain including services and human resource. Appropriate covenants in health and trade policies need to be developed and synchronized to ensure that trade norms maximize health benefits and minimize risks, especially for poor and vulnerable populations. Because of its specificities, health, services and human resource should feature as a separate item in Pakistan’s national trade policy. It is important to realize that policies are living documents and need revisiting to make necessary amendments from time to time.
The author is the founder and president of the think tank, Heartfile. E mail: sania@heartfile.org
Governance Empirics
Published in The News International on August 03, 2008:
Between the government and their critics, opinions relating to the government’s hundred-day performance are at the extreme ends of a spectrum. Unfortunately as a nation, we are not in the habit of being impartial in performance evaluation. The objective of this opinion is not to ascertain whether objectives were met or whether they were reflective of national priorities in the first place, but to emphasize that it is only through impartial empirics and the use of validated instruments and indicators, as opposed to self determined benchmarks, that meaningful inferences relevant to the performance of governance can be drawn. Of the various available tools, this opinion chooses the World Bank’s composite indicators, which measure governance in six domains; the World Bank has recently used this tool for its global report entitled Governance Matters – a cross country comparison assessing ‘broad notions of governance’; a detailed in-country exercise to build further on the data would be timely and useful. There can be many areas for a detailed Pakistan-specific assessment under each indicator; these are being summarized hereunder.
The first indicator is Voice and Accountability. In terms of mainstreaming voice, the government needs to review its current policies on freedom of association, censorship, media freedom, community participation in decision making and public access to information. With reference to the latter, the hundred day performance inventory refers to ‘initializing the legislative process on freedom of information statues’ after repealing the Freedom of Information Ordinance, 2002; here it needs to be ascertained what additional value these statutes will bring to disclosure, which can enable public discourse in larger national interest, in an environment where many secrecy acts can still be invoked to override freedom of information statutes. The government must also objectively analyze how well population and organized interests can make their voices heard in the public sector; the ultimate vehicle for this is the Parliament and a dispassionate review of how effective the Parliament has been as a law making and oversight institution, is an important consideration in governance assessment. Simple perception surveys on trust in the Parliament and satisfaction in democracy can be a useful starting point. Furthermore, the government must also review if it has granted appropriate and due civil and political rights in order to ensure mainstreaming of voice into decision making.
The other dimension measured under the indicator is accountability; it is important to know what strategies are being envisaged to enhance performance and financial accountability of public officials and what measures are being taken to strengthen channels of democratic and political accountability. A range of analytical tools can be employed in this area.
The second indicator is Political Stability and Absence of Violence/Terrorism. Evaluation of governance on this indicator should ascertain how Pakistan scores on attributes this indicator is meant to measure; technically stated, these include political assassination, urban rioting, insurgencies and rebellion, armed conflict, violent demonstrations, social unrest, international tensions, conflicts of ethnic, religious and regional nature, violent actions by underground organizations, extremism and internal conflict. Most of these manifestations have important causal determinants in Pakistan, which an objective evaluation should be able to determine and clearly state.
The third indicator is Government Effectiveness. It does not take sophisticated empirics but public perception and satisfaction level surveys relevant to the quality of supply of public goods such as education, health and public transportation and government citizen’s relationships to give a snapshot in this area. However, on the other hand, bureaucratic quality and governance capability, capacity of political authorities, policy consistency and implementation capacity are hard to measure and the impact of political alternation and policy inconsistency on public services and the impediments created for businesses is difficult to ascertain in tangible terms. What appears feasible however, is examination of the public management process for weaknesses as a proxy measure. For public management to be effective, recruitments need to be merit based, placements should match capacity and functionaries need to be given an enabling environment with due prerogatives, albeit with appropriate oversight. An objective assessment of governance should ascertain the extent to which this is presently the case in Pakistan.
The forth indicator is Regulatory Quality. Pakistan has traditionally employed the command and control style of regulation to correct market failures, which inherently breeds regulatory maladies. Governance empirics should explore the extent to which this has bred unfair competition, discriminatory tariffs, collusion in price and quality controls and licensing and the opportunity to grant excessive protection, over the years and ascertain the extent to which these prerogatives are abused. Here, it would also be important for the government to review its anti-monopoly strategies and competition regulatory arrangements and assess the level of support it is providing to existing institutional arrangements. Additionally, one of the critical prerequisites for ensuring transparency in regulation is to separate the institutional functions of policy making, regulation and implementation, given that mandating the same agencies/ministries with these roles create opportunities for collusion. There have been previous efforts to entrust regulation to independent autonomous regulatory agencies; the government should review the extent to which work on these has been sustained and progress in bridging gaps, in cases where they were apparent.
The fifth indicator is Rule of Law. The level of organized criminal activity (drugs and arms trafficking), importance of the informal economy and tax and custom evasion (under declaration and smuggling) are a measure of the rule of law. It has been anecdotally reported that 70% of our economy is unreported and that more than 50% of the revenue is lost in tax evasion. The government should determine and quantify these losses and delve into their determinants. In addition the enforceability of private contracts, civil procedures and property rights should also be within the remit of qualitative assessments. The current movement to restore the judiciary stresses on independence; however on the other hand matters related to the running, speediness, fairness and impartiality of the judicial process on the whole and the quality of police and judiciary, in general needs a dispassionate evaluation.
The sixth indicator is Control of Corruption. Despite being common, corruption is the most difficult governance attribute to measure as it does not leave a paper trail. Notwithstanding, there are assessment tools that can point to the magnitude and assess trends. Perception surveys, forensic investigations, market, service, exit and price comparison surveys can assist with evaluation whereas mathematical modeling of existing commission rates can give a dollar figure to the amount of resources pilfered from the state system; in addition, putting in place expenditure tracking systems and electronic wage and supply inventories can give data of relevance to corruption empirics while also acting as a deterrent against abuse.
In summary therefore, there is a need to take into account several considerations. First, it must be recognized that poor governance can seriously undermine the functional ability of governments; any sustainable effort aimed at systemic reform of government, therefore must begin with addressing issues of governance; evaluation and assessment has to be the backbone of such an effort. Secondly, that there are various attributes of governance which need measurement and tracking overtime; an objective impartial mechanism and assessment tools that can enable that, must be developed as a priority. Thirdly, that evaluation is just a means to an end and not an end in itself; it is more important to garner the commitment to utilize evidence from impartial evaluations for systemic reform of governance, the envisaged endpoint of this exercise. Finally, it is recommended that the government convene an apolitical independent task force to ascertain current challenges in governance and subsequently set benchmarks for their own performance based on the recommendations articulated therein. As a nation if do not learn to engage in a broader process of reforming governance, things will not change and the overarching issues of dwindling state’s writ, macroeconomic maladies and social sector malaise will continue to prevail.
The author is the founder and president of the think tank, Heartfile. E mail: sania@heartfile.org
Health Policy – chinks in the armor
Published in The News International on July 14, 2008:
In the midst of all the overarching challenges the country faces, sectoral policy and strategy appears to be relegated to the background; the latter cannot be mainstreamed in any case without sound institutional governance, which is also a determinant of the currently prevailing broader issues.
Let’s take the example of health where the government’s initiative to formulate a new national health policy could be the starting point for the much needed reform within the health sector. Certain sound technical choices can be made and if evidenced-based strategies are adopted to synergize a technically robust and administratively feasible agenda, a viable basis for restructuring the health system can be made. However, the issue is not at the level of ‘technical choices’ but with the manner in which institutions govern policy change; there are two critical impediments at this level; first, the ability of state institutions to build on evidence and secondly, their ability to ensure that policy reforms introduced, are taken to fruition over the long term.
A historial review demonstrates that health institutions have faltered at both these levels. Many attempts have been made to reform the sector over the last 61 years. Each time with change of government, institutions back track on initiatives, programs are rolled back and planning begins once more, often regardless of costs or technical merit. Health reform is a long haul challenge. If our institutions do not build their capacity to develop and safeguard a long term vision for the introduction and implementation of reforms, little will be achieved as we continually revisit old ground. Let’s review evidence in support of this statement.
In 1947 Pakistan adopted a curative care approach to health with a focus on producing doctors and setting up civil hospitals; evidence-based recommendations of the Bhore Commission Report (1946), which underscored the importance of prevention were not given due priority. In the 1970’s, in compliance with the principles of Health For All, as stated in the Declaration of Alma Ata, Pakistan established an extensive network of health facilities to deliver Primary Health Care. Unfortunately though, we failed to budget appropriately for sustainability and to analyze the private sector’s impact on the viability of the state’s health delivery system. Today, according to the Pakistan Social and Living Measurement Survey, Basic Health Units (BHUs) serve less than 2% of the population. Despite many efforts in the 80s and 90s as part of the Family Health project, the Social Action Programme I and II and other initiatives, BHUs could not be revived, largely because of the inability to deploy and sustain solutions, over time. More recently, there have been other attempts to restructure. Both the ‘contracting-out’ and ‘reform of directly managed services’ models in Punjab had some technical substance but lessons learnt from evaluations got lost in political turf battles.
During the 90s, successive governments introduced vertical national public health programs following the design stipulations of international donors and international public private partnerships. There has since been an inflow of resources through GAVI, Global fund for AIDS, TB and Malaria, Stop TB, Roll Back Malaria, and others. On a positive note, successive governments have continued with these programs as a result of which they have been able to make some level of improvement in public health outcomes. Their effectiveness can be enhanced further if evidence is factored into planning and problems created by their vertical orientation are addressed by integrating them within the provincial-district accounting and accountability channels. The importance of long term sustained action should be clear to successive governments from their experiences with the Lady Health Worker program, which despite its weaknesses has had a positive impact as a result of being followed through over time.
Let’s turn to hospitals now, where many interventions have been tested in different provinces; the controversial hospital autonomy legislation in NWFP, the Punjab Act on Hospital Decentralization Reform, the Sindh experience with establishment of District Health Boards, and unsuccessful attempts to introduce hospital based private practice in NWFP. The emphasis in all of these has been on cumbersome statutory and governance rearrangements. Exceptions notwithstanding, simple evidence based interventions such as delegation of financial and administrative authority to trained managers and fully autonomous boards has not been tested in the truest sense.
In relation to health financing, contrary to what is generally believed, many options have been tested. Pakistan established the Employees Social Security Institute in 1967 based on the US model, just a year after it was introduced in the USA. Today the same scheme in the US forms the backbone of Medicare, whereas Pakistan only covers 0.84 million employees in the private sector, with many opportunities for expansion untapped. Enhancing revenues as a means of financing health was tested in the SAP years and more recently as part of the increase in fiscal space in the last five years; limited ability within the system to expend and target funds was found to be a key impediment to achieving envisaged outcomes; however, lessons learnt have not been mainstreamed into planning.
Every government wants to introduce health insurance and appears to address the subject de novo; the writer has addressed this subject in these columns on June 28, 2008 to propose a way forward building on the many un-leveraged programs currently on ground. The needed complex organizational changes and restructuring of social welfare, can only be implemented through long term evidence-based reforms.
Let’s turn to institutional and decentralization reforms where many examples of missed opportunities can be cited: these include efforts as part of SAP in the 90s to decentralize social services, albeit in a centralized government system, the management intervention in Sheikhupura under the Family Health Project, establishment of District Health Authorities and District Health Management Teams in 1996, and setting up of District Health Governments in 1997 under SAP II. Despite these efforts consolidated recorded evidence is not in the public domain and lessons learnt cannot be factored into planning. Each of these is a legacy of backtracking on what could have been a viable intervention if followed. It is feared that the same will happen to the Devolution 2002 initiative. Another case in point are efforts to integrate the ministries of health and population. Since the 1970s, successive governments have attempted to constitute committees, commissions, boards, sign MoUs and issue joint calls to integrate. Yet each time new avenues are explored. The word limits on this opinion preclude a reference to similar examples in pharmaceutical, human resource and other domains but each has a similar story to tell.
The lessons learnt from these examples can be summarized in a nutshell; over the last 61 years, there have been a number of attempts to mainstream change in the health sector. Governments have adopted options with subsequent governments disregarding them. Institutions have had limited capacity or time to consolidate lessons learnt. Those in technical and administrative roles in ministries and departments do not appear to have the voice, or tenure security needed to make it implicitly binding on incoming governments, to conform planning and action with evidence. Consequently, every government starts de novo as plans in the pipeline are rolled back, resulting in significant wastage of tax-payers money. Regrettably there is no mechanism to hold governments accountable for such actions. Although the case of health has been showcased in this opinion, the story resonates with similar experiences in other sectors as well.
The question of developing a new health polity therefore has to be addressed within the context of a long term vision for reforming a sector. It is important not only to develop a consensus of all the political and technical stakeholders on the technical modalities but also a mechanism to safeguard a vision over time; failing that, the policy will remain a wish list.
The author is the founder and president of the think tank, Heartfile. E mail: sania@heartfile.org
Romancing health insurance
Published in The News International on June 28, 2008:
With all the four provincial budgets for the fiscal year 2008/09 tabled, the annual provincial development programs for the next year have been unveiled. Provincial development budgets range from 22.12-41.13% of the total outlays with Punjab spending the highest and Balochistan the lowest. 1.84-12.15% of the total provincial development budgets have been allocated for health with Sindh allocating the highest in relative terms. On the whole, provincial health allocations suffer from limitations that are somewhat similar to those described for the federal health budget in the author’s editorial in The NEWS on June, 20. However, a consistent reference to health insurance as a potential means of financing health in budget speeches has prompted this opinion in an attempt to bring clarity to the potential therein.
First of all, it is important to recognize that there are broadly two means of financing health – public and private; public sources, which include tax and pooling (social health insurance and exemptions are the two ways of pooling) are more equitable in protection against health expenditure than private sources, inclusive of private insurance and out-of-pocket payments. Public sources must therefore be prioritized. However, as opposed to this, private out of pocket payments account for 70% of the means of health financing in Pakistan, as is the case in many other developing countries. Revenue allocations for health currently stand at Rs. 270/- per capita. In view of the need for investments of the order of Rs. 2,700/- per capita, per year and limitations to correspondingly enhance revenues, other options for financing healthcare clearly need to be explored.
The potential within social health insurance (SHI) as a mean of financing health has been explored times and again in Pakistan. Official development agencies and experts have advocated the need for its mainstreaming into planning, but governments have been unable to institutionalize arrangements.
In the early 1990s, World Bank and Japanese bilateral assistance supported a health insurance pilot in NWFP, which was later discontinued. More recently, when the Asian Development Bank provided technical assistance to the Government of Pakistan for social protection in 2005, it envisaged five areas of which social health insurance was one; its development study (ADB TA 4155-PAK) had a component on health insurance, which recommended the introduction of a social health insurance scheme on a ‘start small and grow’ basis. However, the final Social Protection Strategy, 2007 did not appropriately include health in its core instruments. In NWFP, German bilateral agencies have focused on introducing SHI with support from the religious community capitalizing its non-profit solidarity characteristics. The Federal Government has also looked into the possibility many times and Government of Punjab has constituted task forces to explore options. Each evaluation reiterated the need to build this as an option for financing healthcare in Pakistan.
The priority now is to develop a concerted vision for a way forward. Whilst it is important to draw lessons from other countries where public sources of financing ensure universal coverage, a way forward must be locally suited. In this context it would be important to note what the current sources of public financing are, and the potential within them to be scaled up. As a first step, there is the need to earmark a higher percentage of revenues to finance the delivery of a package of essential services. In terms of the alternative public sources, opportunities in Pakistan can be categorized based upon whether they apply to the formally or the non-formally employed sector.
First, Social Security, which is one of the five charges imposed by labor legislation on private employers in Pakistan, supports an insurance scheme under which private employees in a certain category receive healthcare through the health infrastructure of the Employees Social Security Institutes in three provinces. There are an estimated 5.65 million employees and their dependants covered under this. The government should use this as a platform for increasing social health insurance coverage for those in the formally employed sector.
Secondly, there are an estimated 0.8 million individuals and their dependants covered under private health insurance in the corporate/private sector. As such there is limited role of private health insurance in Pakistan as the primary source of coverage because of issues of affordability; the only countries in the world where private health insurance is mandatory and therefore a major mode of financing healthcare are Switzerland and Uruguay. Growth of private health insurance is correlated with economic growth in general and growth of the formally employed sector in particular. It is only when employers subscribe to global employment practices and factor in health benefits for a large number of employees that health insurance companies with investment capacities and appropriate domain experience have an incentive to operate in developing countries; by underwriting a large number of people in a pool they can also create an opportunity health providers would wish to avail and may compete for, hence bringing down costs. The government should therefore analyze the current policy environment for private insurance companies balancing financial incentives with appropriate safeguards and explore incentives for employers so as to encourage them to subscribe. However, in doing so, they should ensure that these measures help to decrease inequities.
Thirdly, there are examples of community health insurance within the country; this involves not-for-profit pre payment plans with voluntary membership. In general, the cost implications of administering policies in far flung rural areas when transferred to the insured generally make the premium unaffordable, standalone. However, microfinance institutes (MFIs) in Pakistan are attempting to address this issue by offsetting administrative costs in pilot projects; these involve one time purchase of policies, which MFIs sell to their clients; some initial encouraging results have been demonstrated. In this case the government should attempt to offset the risk associated with their size and vulnerability by providing subsidies and underwriting costs.
The forth option for pooling is through cash transfers. Theoretically, a local government certified Zakaat form entitles the needy to free services that involve a user charge in public hospitals; high cost diagnostic and invasive procedures not funded through Zakat are meant to be financed through the Bait-ul-Mal. However, there are many weaknesses in this system; in addition, the funding pool has a narrow base; only 11% of Zakat funds and 8% of Bait-ul-Mal funds were allocated for health in the year 2007/08. Here the priority for the government is to broaden their base for health, but more importantly introduce transparency promoting measures in governance that can eliminate the wide scope for patronage and abuse and discretionary use of power and exploitability of procedures in targeting social protection funds.
The issue of health insurance therefore has to be seen in the broader context of the need to expand public financing in order to provide universal coverage for healthcare. Expanding the base of social health insurance for those in the formally employed sector and community insurance in cases where it is sustainable, the use of private insurance for equitable outcomes and broadening of the base of exemption systems will help to enhance public sources of health financing and will contribute to social health protection; these measures need to be prioritized in the short to medium term. As a long term goal universal social health insurance and restructuring of social welfare and social security systems should be pursued. These necessitate complex organizational changes such as separating provider and purchaser functions, enacting appropriate legislation and building further on the system of individual registrations through the National Database Registration Authority. It must be recognized however, that these changes can only be brought about by institutions that project long term and have the ability to cascade complex changes into concrete action.
The author is the founder and president of the think tank, Heartfile. E mail: sania@heartfile.org
Budget – five points under the health lens
Published in The News International on June 21, 2008:
Had it been conventional to place the budget in the public domain to solicit inputs of the civil society on the directions proposed therein, suggestions such as the one articulated in this opinion could have been more timely in terms of possible inclusion in the planning process. Given that this is not the scenario, the following five points are offered as policy inputs in relation to budgetary allocations for health, on the premise that some of these ideas will generate a discussion in the forthcoming parliamentary debates.
First, it is important to recognize that the health status of populations has a direct correlation with the level of public spending on health. However, it is not just the aggregate level of spending, but the percentage of GDP allocated for health adjusted for inflation and population growth, and its translation into per capita public expenditures relative to private expenditures that gives a somewhat truer picture of the state’s investments in health. Here it is acknowledged that Pakistan’s aggregate level of allocation for health has increased considerably over the last decade with further increases in this budget representing a positive trend. However changes in health allocations as a percentage of GDP have remained unremarkable; over the last 10 years this has ranged from 0.67% to 0.8%. Although this year’s figure is not in the public it will be within this range as opposed to the internationally recommended 4% of the GDP. Currently, the public sector spends US $ 4 per capita on health annually as opposed to the internationally recommended US $ 34 per capita, the minimum required to provide essential health services in developing countries. Clearly, this huge gap needs to be bridged.
Triangulation and analysis of health expenditure patterns across agencies in Pakistan providing comprehensive health cover to employees and their dependants, demonstrate that delivery of health appears plausible at an expenditure level of Rs. 2,700 (roughly US $ 42) per capita, annually in Pakistan. This is still significantly lower than what some other developing countries spend on health. Assuming Rs. 2,700 as the benchmark per capita public health expenditure for Pakistan, it is recommended that the government should present a five year plan to incrementally enhance allocations. Although it may not be possible to reach the goal in five years, targeting the goal can set a precedence to enhance allocations over and above the Fiscal Responsibility Act stipulation of doubling health allocations over a ten year period.
The second point is in relation to the current skew in favor of private sources of health financing, as opposed to the desired public sources. Approximately 70% of healthcare in the country is financed through out of pocket payments made to health providers at the point of care. This is the most inefficient and inequitable way of financing healthcare. Idealistically, health should be funded through public sources, which include revenues, social health insurance or other means of pooling such as social protection. We cannot expect miracles to turn this equation around overnight; it is accepted that it is only through long term structural measures that the skew might even out if appropriate policies are adopted and sustained overtime. Whether the present government can do that is a separate debate and one that will be the focus of another opinion. Relative to the present discussion, it would be appropriate to introduce certain short to medium term innovative measures. These could include earmarking of a higher percentage of Zakat and Bait-ul-Mal funds, over and above the current estimated 15% for health, ring fencing these funds into a transparently governed health equity pool, and the creation of the an efficient delivery instrument. Another quick win could have been modification of the eligibility criteria under the Employee’s Social Security Institute, to include a wider segment of the population, or creating better linkages of health under current labor legislation, or simply expanding the scope of cash transfers under Benazir’s Income Support Program to protect the poor against catastrophic spending on health; the latter according to the Planning Commission’s 2007 Social Protection survey, are the commonest cause of economic shocks to households in a poverty precipitating context. The creation of a financial tool to make it implicitly binging on district governments to spend a certain percentage on health is another low lying fruit. Although these opportunities have been missed, there is still time to explore them during the budgetary parliamentary sessions.
Thirdly, the budget does not appear to be concerned with utilization and targeting issues. The 20% lag in allocation and expenditure observed over the years in various health agencies is telling, as is evidence related to the wide scope for patronage, abuse, discretionary use of power and exploitability of procedures in case of targeting resources to the poor. It has been estimated that the cumulative value of resources pilfered, mis-targeted and ineffectively handled are more than a staggering 50% of the total health budget. In order to address this, certain invisible measures are needed. Strengthening capacity to streamline national health accounts, leveraging technology to minimize leakages from the system and measures to promote transparency through the creation of electronic public expenditure tracking systems and payment inventories are some measures, which can lead to major gains in the long term. Budgetary allocations in these areas are not evident and it is strongly urged that some of these strategies should be budgeted for.
Fourthly, the classical budgetary disparity evidenced in priorities for allocating resources for preventive healthcare is obvious. According to the Federal Bureau of Statistics’ Pakistan Demographic Survey, it is documented that more than 50% of deaths are due to non-communicable diseases (NCDs). However as opposed to this, only 0.66% of the total healthcare budget has been allocated for the prevention of these diseases. NCDs, a collective name given to the diseases of the heart, diabetes and some lung conditions and cancer, incur significant costs in healthcare, undermine income generating capacities of the productive workforce and have the potential to perpetuate acute poverty crises. There is an expectation that a new government will engage the much needed reengineering of public health priorities; due attention must be paid to this.
Fifthly and following on the same note, there was also an expectation that there would be a move away from the output-driven approach as evidenced by new target setting in the number of Lady Health Worker and recasting of old programs to some strategic restructuring interventions that could help the new government achieve its stated commitment embodied within the creation of a national health services as articulated in their manifesto. There are many imperatives for restructuring a health system that has fundamental flaws and where governments attempt to finance and deliver services in an environment where the private sector operates in a completely unregulated market. A policy, legislative, regulatory and institutional overhaul in health has been long over due.
The government could have signaled a commitment to overhauling the health system by reorienting priorities for allocating resources and earmarking seed funding for innovative pilots. The beginnings of that are not evident in the directions of the budget. Nonetheless, let us give the new government the benefit of doubt. Perhaps time and situational constraints precluded attention to this matter and an opportunity was inadvertently lost. The parliamentary debate would be the next opportunity to weave in some strategic measures, which can then be built upon further in their new health policy. If that opportunity is not leveraged, they will not just miss the boat but also the chance to take initial steps to consolidate the egalitarian premise of their manifesto and the opportunity be true to the reference to social justice in its preamble.
The author is the founder and president of the think tank, Heartfile. E mail: sania@heartfile.org
Pakistan’s Covert Cartels
Published in The News International on May 22, 2008:
With economic, food and energy crises looming, criticism can be the most convenient past time. Such situations however, are also the litmus test for patriotism, given that a true commitment to the country warrants a look into the present and past for an objective empirical analysis only to develop insights for future planning and action. It is in an attempt to do the latter, that a viewpoint is offered.
Crises illicit a knee jerk reaction to trouble shoot and inadvertently lead to fleeting short term solutions; however, it is equally important to explore their causal determinants for long term sustainable action.
Let’s take the wheat crisis as a case in point, a crisis that affects the common man directly as opposed to many other crises in the spotlight, that don’t. After a careful evaluation, it becomes evident that the crisis is just the tip of the iceberg and that its manifestations, price hike and shortages, are an indication of deep-seated systemic issues, just as fever indicates infection or unexplained rains herald climate change trends. These systemic problems encompass all shades of mal-governance from inefficiency and ineptitude to blatant corruption. What the wheat crisis simply denotes is the seamless capacity of vested interest groups to hoard and smuggle in an environment where state institutions have very little capacity to enforce compliance with stipulations, check the alleged industry-cartel collusion and ensure the intended movement of commodities. It also illustrates hallmarks of a system where there is limited accountability of public officials either for not taking preemptive timely decisions that can help avert such crises by checkmating cartel activity or paradoxically for decisions that favor vested interest groups. It also spotlights institutionalized collusion between the private and the public sectors at various levels.
These malpractices help to further strengthen Pakistan’s growing informal and black economies, which thrive on smuggling, trafficking and a range of financial crimes. The money generated from the wheat crisis is just a paltry contribution.
When evidence from the wheat crisis is triangulated with lessons learnt from other ongoing crises, the existence of a triad is clearly evident: weak governance structures, a thriving black market and a legacy of patronage. This nexus breeds and promotes a form of governance where systemic manipulation is fast becoming the norm. In such an environment, state capture by vested interest groups becomes a real threat and the undue influence to shape state policies, laws and regulations can divert resources to the resourceful. In addition, misuse of authority can be augmented with resulting preferential treatment to well connected individuals and collusion in public procurements. Such environments also promote tolerance to circumventing procedures to settle police cases, change land documents, evade tax and get permissions and licenses – processes where transparency is critical. As this triad gets firmly ingrained, there is a danger that political links are furthered by patronage. The resulting outcomes can be devastating in the long term; state resources get channeled to the well connected, the rich poor divide is augmented, institutions loose their leverage to target services and subsidies to those in need, governance becomes exploitable and reforms are held hostage.
It is tragic to coin this as a description for a ‘system’ that can boast of many ‘individuals’ of unquestionable integrity in every sector of the country; but sadly there is evidence of these phenomena taking root in the country. We have recently seen that budgetary increases in the social sectors fail to create the desired impact because of the seamless capacity within the system to pilfer resources. We have also seen that any systemic reform introduced to improve governance is implicitly undermined. The manner in which the interests of local elite to control resources at a district level have weakened the devolution initiative is a case in point.
As an outcome of all these malpractices, we see the emergence of a system that denies impartial and timely settlements of disputes and one that manipulates sudden dismissal and transfers of state functionaries without the benefit of impartial inquiry if they attempt to threaten it in anyway – a phenomena many upright and sidelined public servants of Pakistan have become painfully familiar with over the last 60 years.
As a nation we tend to underestimate the impending costs of the loss of professionalism, neutrality, accountability and transparency. That it can lead to plundering, pilfering and mis-targeting of resources is well appreciated; but many may not be aware of the implications of this well established pattern for weakening the social fabric, undermining the safety of our populations, risking national sovereignty and threatening peace and security.
Those of you, who are inclined to disregard this as a sweeping, emotional and overrated statement, may want to argue by referring to the lack of transparency as being a global systemic issue. Pakistan is certainly not the only country with such well institutionalized practices; but there are other country characteristics, which make us potentially vulnerable. It is important to know why that is so.
We are the sixth most populous country in the world; more than 30% of our population is below 15 years of age; with high levels of poverty and unemployment, this segment of the population becomes vulnerable to exploitation. If the state’s leverage to target services, subsidies and social benefits continues to erode, capture by vested interest groups will become highly likely. The story of ‘bleak youths’ in this weeks TIME magazine is telling in this regard. We must also recognize that there are many opportunities for capture. As a society, we are deeply divided on ethnic and religious grounds; as a nation, we have a unique pattern of civil conflict and violence since the cold war era; as communities, we are polarized on many sociopolitical and foreign policy positions. In this environment, there are well established patterns of exploitation. If governments cannot be the efficient and honest redistributive hand, the current exploitation will further deepen and is likely to be further worsened by the impending impact of the global and regional food and energy crises.
The government, therefore cannot afford to disregard the issue of malgovernance and corruption; however, while doing so they must refrain from what has been the convention in the past – fleeting coercive action and using corruption as a tool for political exploitation; neither of these approaches are useful for sustained meaningful action and undermine the credibility of reform.
An anti corruption reform is a huge agenda but if seven things need to be done, they could be grouped into the following categories: first, planning strategically and reviving the dormant National Anti Corruption Strategy. Secondly, ensuring that Pakistan’s key accountability institutions for public redressal, oversight and investigative work are impartial and depoliticized. Thirdly, prioritizing integrity promoting measures in the establishment through a combination of merit based action and incentivization. Fourth, promoting market harnessing means of regulation and fostering competition to weaken economic interest. Fifth, focusing on disclosure and conflict of interest in civic action, judiciary and political party finance. Sixth, rooting out arbitrariness, the unchecked powers of discretion and unevenness in the application of policies in state institutions; and seventh, a move towards mainstreaming technology into governance, so that leakages are tracked and public procurements are made transparent.
Governments must recognize that corruption cannot be rooted out in a big sweep and that governance cannot be effective overnight. Governments must proceed incrementally and remain non-confrontational and apolitical. The key is to safeguard against capture and foster transparency in regulation, oversight and management of resources through joint action between the government, civil society and the private sector. All of us must play a part to reform a system of which we are a part. However the ultimate onus of responsibility lies with the government.
The author is the founder and president of the thinktank, Heartfile. E mail: sania@heartfile.org
Honing the 100-day agenda
Published in The News International on April 06, 2008:
Perceived as an effort aimed at planning strategically the Prime Minister’s 100 day agenda is a step in the right direction. The points articulated therein are substantively valid if implemented in their true spirit. Their contents however, are a mix of long term aspirational goals, preferred policy choices, strategic administrative measures and a few immediate executive orders.
Ideally the hundred day agenda should sift and separate the aspirational vision from the steps needed to implement the vision and subsequently cascade the latter into tangible processes that the government can pragmatically initialize within the stipulated period. It is hoped that the government will engage in such a strategic planning exercise to hone the agenda further and it is with the intent of contributing to this exercise that a neutral viewpoint is offered.
To begin with, the overarching context of the agenda should be brought to bear; this clearly flags three imperatives: instituting mechanisms so that individual and group interests become subservient to state interest; strengthening institutional integrity; and making governance effective to enable the government to achieve broader goals within the sustainable development, macroeconomic and security realms.
First, in relation to upholding state interest, the agenda’s commitment to a free media and restoring trade and student union activities is welcome. This can enable strengthening the societal political culture and reinforcing democratic linkages between the government and the society, which are getting increasingly tenuous. However in doing so, the government should formulate procedural values so as to build safeguards against vested interest groups.
Secondly, measures within the 100 days to foster institutional integrity and legitimacy of state institutions are important; while some measures are being taken, others that safeguard against abuse of power, patronage, monopolization, collusion and arbitrariness are needed. A conflict of interest and disclosure policy, specific measures of public oversight and legislative scrutiny or whistle blower protection laws for individuals in high risk environments would be symbolically significant in the 100 days and can be built further upon, later.
Thirdly, making governance effective on the whole needs a set of measures to strengthen and reconfigure structures of the state and instruments of governance; these are beyond the scope of the present comment, but within that remit, relevant to the hundred day agenda are some caveats. The agenda’s preference for setting Commissions in many areas should be carefully reviewed. Commissions can be given specific roles over a time frame for exploratory and analytical purposes or on a more ongoing basis they can be mandated in a watchdog role. It is assumed that the envisaged Truth and Reconciliation Commission falls within the rubric of the latter and may be a good idea. However, commissions setup to ‘deliver on an egalitarian premise’ in the social sector areas, can duplicate the work of ministries and departments and take the focus and resources away from the much needed attention to why ministries and departments fail to perform in the first place. For example, the fundamental reason why successive governments have failed to deliver in health and education is because of the interplay of market dynamics in both areas, the solution to which lies in splitting financing and provision functions and leveraging markets to deliver social goods; this necessitates revamping line ministries from policy, regulatory and operational standpoints; setting up parallel institutional structures will be of limited value in that regard.
Similarly, relevant to governance is the new government’s executive order that makes PEMRA subservient to the Ministry of Information. The discussion on the suitability of that approach from a technical standpoint is not the intent of the comment here but the fundamentals that underlie that from a broader governance perspective are. Separating ‘policy making and normative functions’ of state agencies – a mandate of ministries – from ‘regulatory and operational functions’ and housing the latter in autonomous agencies on the premise that this obviates conflict of interest is a fundamental policy stance that is being pursued as a broader governance goal to support the neo-liberal agenda Pakistan has been pursuing. The decision to go back on that has implications for international commitments and compliance with conditionalities for development assistance and is something that necessitates a careful look into.
Also of relevance to governance is the issue of provincial autonomy and abolition of the Concurrent List. This radical, but needed measure would have to be taken step-wise. Rather than capping the one year time frame, it would be more feasible to outline the steps needed for successful implementation after a careful review of capacities in respective provinces and taking inter-provincial differences into account. Of course the Concurrent Legislative List cannot be abolished completely; the agenda itself is evidence of that and the reference to a uniform curriculum in education is a case in point. Other examples include Pakistan’s obligations under WHO’s International Health Regulations, where a strong federal role is needed. In addition economic coordination, standard setting, monitoring and evaluation will also have to be centrally coordinated for many sectors under the Concurrent List.
The agenda also reiterates a commitment to full employment. It must be appreciated however that as a goal, this has been impossible to achieve even in the most affluent nations. The revival of Pakistan’s stalling economy is the most logical measure to improve employment rates. However in the event of the government being committed to pursuing this as the compelling objective, innovative options will have to be developed. Lessons from the economic revival and employment spur in the aftermath of Word War II and after the Great Depression of 1939 are instructive in this regard, where public works schemes boosted employment as well as built much of the infrastructure in the United States we see today. Pakistan will be constrained in its ability to go that route with infrastructure being funded by the public sector because of the recent and impending cuts in PSDP; but there is a novel opportunity to leverage the existing institutions in Pakistan created to harness the potential within private sector investment for infrastructure development. The existing law, policy, task forces, standard provisions, the risk management framework, the Infrastructure Project Development Facility already developed and mechanisms of viability gap funding need to be capitalized for this purpose. While striving to boost employment, lessons from mass political inductions in state controlled autonomous agencies in the past are also instructive as facilitating employment without regard to institutional sustainability can be damaging. Clearly the envisaged employment commission must not pursue that stance.
The Prime Minister’s austerity measures are symbolically welcome as they aim at saving precious public resource; this must however be matched with efforts to plug much larger pilferages and leakages from the state system. The 100 point agenda does refer to curbing corruption and has abolished the controversial NAB; however an anticorruption reform has to carefully balance mechanisms of public redressal, oversight, accountability, investigation and prosecution. It would be important for the new government to present an impartial and incorruptible anti-corruption model within the 100 days.
Finally, the new government must consider the inclusion of another item in the 100 day list; it is critical that they present their position on the devolution initiative; however in doing so they need to be mindful of the fact that principles of decentralizing and local self governance can assist with egalitarian outcomes and the provision of basic public goods – values that the coalition manifestos are grounded in. The 100 day plan must also be evaluated at the end of the period in a participatory style with relevant inputs; on a positive note, this will enable the government to analyze not just the feasibility of their policy agenda but also the chinks in their own armor.
The author is the founder and president of the thinktank, Heartfile. E mail: sania@heartfile.org
Anti-corruption reform – strategic imperatives
Published in The News International on March 18, 2008:
Elections 2008 will soon come to fruition with the formation of a new government. Regardless of who assumes office, being in the government is not going to be an enviable position if the ground reality is brought to bear, as it should. As practical action replaces rhetoric, limitations of the government to deliver on election catchphrases will become evident, particularly in serving the needs of the disadvantaged.
The foreseen inevitable worsening of inflation is likely to put a tremendous pressure on the impoverished masses whereas the stalling macroeconomic situation will constrain the government’s ability to allocate additional development budgets. Failure to improve social conditions will ultimately have implications for many deep seated issues we face today, such as violence and instability. In order to do something meaningful therefore, certain insightful policies will have to be pursued beyond quick actions demanded by political expediency.
In the quest for a sustainable solution, the new government might want to consider a common determinant that has led to most of the maladies faced by the country over the last 60 years and a cause that is widely under-rated in terms of its impact to undermine the effectiveness of governments – the determinant is called ‘lack of transparency’.
Most of the problems today stem from it directly or indirectly. Food shortages are related to cartel activity; violence and conflict are the outcomes of lack of transparency in decision making whereas gaps in institutional accountability – an indicator of the level of transparency – is responsible for the present energy crisis.
Lack of transparency also has a direct bearing on other systemic issues that often make headlines; nepotism in human resource hiring and political inductions over the years are responsible for many issues faced by public sector institutions; politicization of decision making undermines the strength of ministries and collusion in public procurements over the years has led to pilfering of public resources including humanitarian aid and emergency procurements. In addition, preferential treatment to well-connected individuals leads to mis-targeting of services and subsidies whereas deliberate inattention to oversight leads providers in health and education to serve in the private sector. Most importantly, state capture and political patronage biases the policy environment to favor the elite.
The actual volume of revenue lost has never been calculated; however, estimated losses of US $ 3.3 billion through tax evasion alone is the tip of the iceberg; the staggering costs of commissions in public procurements, revenue lost due to crony privatization and political patronage and the shadow economy all incur huge losses. In addition to mis-targeting resources and augmenting the rich poor divide, lack of transparency and corruption in their fiscal, ethical and procedural forms, undermine political, social and economic development and threaten stability, security and ethical values in a society.
It is recognized that ridding the country of corruption requires deep-rooted systemic reform; it is impractical to expect miracles overnight. Notwithstanding, certain implicit transparency-promoting measures by the new government are critically needed rather than coercive action, as has been the norm. The following can be pragmatically achievable in this regard.
First, in relation to policy and strategy, it should be recognized that Pakistan is a state party to the UN Convention Against Corruption, the international reference framework for anti-corruption work; this can provide an entry point to reenergize Pakistan’s National Anti-Corruption Strategy (NACS). Many flaws in NACS have been flagged overtime; these include its orientation as an ambitious broad set of recommendations rather than the living documents needed to ingrain structural reform and its overall inspirational character removed from economic and political realities of implementation. Despite these limitations, NACS is a coherent strategic framework and the next government should ideally develop intra-agency sub-strategies based on the analysis already conducted. In doing so they must also develop mechanisms of parliamentary oversight and civil society engagement.
Secondly, it is important to bridge gaps in institutional mechanisms relevant to anti-corruption reform. Mechanisms of public redressal exist in the form of the Ombudsman’s office but have a narrow mandate; here legislative action to include anti-corruption work within the institution’s remit and linkages with public participation bodies such as Community Citizen Boards appears feasible. The commitment to create an Ombudsman’s offices in every district, as envisaged by a party manifesto is a hugely important initiative if appropriately structured. Oversight institutions include the Public Accounts Committee and the Auditor’s General Department; these need to be strengthened as a tool for public sector accountability. In relation to investigative work, NAB is an important investigative arm of the state, which must be strengthened to engage in impartial pursuits; this can be done by making governance broadly representative and by fostering an open disclosure policy. It must be recognized that there is adequate institutional infrastructure in place for anti-corruption work. Pakistan also does not need new Statutes. What is required is the will to enforce, which will get the new government started on a moral high.
Thirdly, it is important to institutionalize integrity promoting measures in the public sector. As an initial step, it is important to ensure while appointing cabinet members that they have no conflict of interest in terms of major business involvements relating to respective ministries; this is a critical safeguard against patronage and support for debt writing off, tax exemptions and other favors.
In addition, existing reforms should be used as an entry point to promoting integrity. The macro-policy stance to separate the policy-making functions of ministries from regulation and housing the latter in autonomous agencies is important for fostering transparency in regulation and needs to be built further upon. Similarly, civil service reform aimed at developing systems of compensation adequate to sustain livelihood and institutionalizing accountability, initialized through the work of the National Commission for Government Reform, needs to be further built upon. Efforts to promote integrity should also reenergize development partner efforts to promote transparency in governance as in the case of the Access to Justice Project of the ADB, the Project to Improve Financial Reporting and Auditing of the World Bank and likewise other such efforts.
In the fourth place, certain implicit transparency building measures should be prioritized. The use of technology can be helpful in this regard and can enable plugging leakages from the system, obviating unauthorized payments, eliminating abuses such as paying ghost workers seen in the health and education sectors and promoting greater transparency in procurements. Providing a level playing field for businesses and fostering competition can weaken economic interests that promote state capture; in this regard, the recently created competitiveness commission can provide an entry point.
Finally, it is important to strengthen the countervailing forces of the state – the parliament, judiciary, media and the civil society. Whilst doing so it should be remembered that corruption in the subordinate judiciary and politicization of the superior judiciary is well recognized; that capture of the media by vested interest groups is a potential threat and that the civil society, which is seen as a panacea for all ills and appears altruistic may, in certain cases, have very complex motives. It is also not fair to blame the executive branch of the state entirely for the prevailing lack of transparency, as the onus of responsibility lies with all the actors in the state system as well as the private sector; the latter is both a beneficiary as well as a victim of corruption as a result of public private collusion.
There can be no generalizations here; bonafide and non-bonafide entitles exist in every structure and it is the role of the government to provide safeguards and to be the honest hand that separates shades of grey from the black and white. The new government should place this high on its list of priorities.
The author is the founder and president of the thinktank, Heartfile. E mail: sania@heartfile.org
The Social Sector – telling evidence
Published in The News International on January 30, 2008:
In its report entitled “The State of the World’s Children, 2008” UNICEF’s reiteration of Pakistan’s stalling position to meet the targets stipulated in the Millennium Declaration particularly with reference to MDG 4 and 5 adds yet another set of predicaments to the ones that already exist in the country, on a range of fronts. Much of what has been articulated in the report is not new though; we have known about our poor maternal and child health indicators for a while through state-owned data that is in the public domain and many international peer reviewed publications; but perhaps a multi-lateral’s technical weight might help to drive the nail home further.
What has hurt our national pride this time around is to see our indicators being compared with countries such as Afghanistan with whom we have no comparison in macro economic terms and to see countries in a similar per-captia income category, with far better indicators on child mortality.
Here it must be recognized that this is not just ‘another report’; the data have a serious connotation as child mortality is a sensitive indicator of a country development and evidence of its priorities. It is about time that we reflect back on where the issues actually exist as there has to be something wrong with the way things have been done in the health sector over the last decades, despite significant resource inputs.
It must be acknowledged that as a starting point that many determinants of health lie outside of the realm of the health sector. Health has a direct correlation with poverty, illiteracy and inequities in the society. In many Far Eastern countries increasing the level of female education has been the single largest factor in decreasing child mortality levels. It is also well-established that one of the best determinants of health status achievement is the level of per capita income. In addition, much of the scope of public health work is conventionally placed outside medical care service in any case, particularly with reference to the provision of clean water, solid waste disposal and ensuring food security. The larger burden of infectious diseases responsible for most of the child deaths alluded to in the report is known to be closely related to the lack of sanitation facilities and safe sources of potable water. Therefore a focus on the health sector alone to improve health outcomes is not good enough. The potential to address these issues through comprehensive development initiatives falls within the rubric of the social sector.
The social sector compromises a diverse range of interventions, programs and policies and has many components. These range from services (health and education), income generation (publicly funded safety nets, cash transfers, low wage employment, public schemes, charities, microcredit, pensions and benefits through insurance), subsidies (such as in the case of wheat), infrastructure (water and sanitation) and benefits (unemployment, feeding, pensions, old age benefits and housing). These can be delivered through a range of interventions and programmes, which may be safety net based, social insurance supported, community programme oriented or labor market and infrastructure targeted. Pakistan has many of these initiatives on ground: Zakat, Bait-ul-Mal, many labor welfare schemes, Khushaal Pakistan program and the currently controversial Tawana Pakistan program, etc. Despite their existence a number of social sector impediments exist in the country, which hampers the state’s ability to deliver on a social sector premise. We must know what these are before attempting to rectify them.
First is the challenge of fragmentation and lack of coordination in the social sector; other than a member in the Planning Commission there is no institution mandated with the responsibility of coordinating social sector activities, which are deeply linked inter-sectorally. In addition, the “inadequacy of existing programmes in terms of coverage and funding and lack of supervision”, was acknowledged in Pakistan’s Social Protection Strategy by the Cabinet Minister in charge at the time of its publication, recently in 2007. These factors lead to limitations in targeting, duplication and overlapping.
Secondly, alarming as it may seem, Pakistan does not have a social policy. Although there are individual policies on Housing, Labor Protection, Health and Education, Pakistan unfortunately does not have a social policy per se, which articulates Pakistan’s definition of social services, the choices concerning those services, their range and most importantly, the means of their provision and the mechanisms of their financing. Here it can be argued that Pakistan’s Social Protection Strategy of the Planning Commission is a policy document. However, its focus on “supporting vulnerable households and the poor and the vulnerable” aims its strategies primarily at benefiting the poor. It is true that the original motivation for the expansion of welfare services should be to help the poor, but evidence has shown that anti-poverty policies have their limitations in reducing unjust social disparities and therefore action beyond poverty eradication is needed to benefit the middle classes.
The creation of an overarching social policy should therefore be regarded as a priority. In addition to delivering programs referred to above, a sound social policy can remove or mitigate social inequities created by the market system and can ensure that the government still has the leverage to play a redistributive role through means other than regulation in an environment where the government is pushing the balance in the economy in the direction of private rather than public ownership.
The third challenge more specifically to health is the ‘health system’ itself. Pakistan’s health system’s preoccupation with vertical disease prevention interventions has harbored an inadvertent neglect of health systems over the years; programmes simply cannot be delivered if the fabric of health systems in not strong. Here it should be realized that Pakistan’s health sector has a strong post-colonial imprint as it is designed on the Bhore Commission’s report recommendations (1946). In theory, a national health services model exists with the three tiers of service delivery infrastructure but in actual effect, insufficient financing of publicly funded health services, an unregulated role of the private sector in the delivery of care and issues inherent to the utilization and targeting of state resources – generic to all social services – defeat the ultimate objective of ‘health for all’, systemically. Achieving this objective in Pakistan’s current health system will entail introducing and supporting alternative health financing and service delivery arrangements. With innovative strategic planning, these can enable the country to provide universal coverage for a certain set of interventions through public revenues and provide alternative ways to achieving the equity objective for other health interventions.
This involves a major shift in strategy and change in the policy, legislative and regulatory environment in the health sector. In addition to having implications for enhancing capacity in governance, this change entails the creation of frameworks for public-private partnerships to engage with non-state actors that play a major part in the delivery of health in Pakistan’s mixed health system; the change also necessitates that the health sector engages inter-sectorally with social safety net arrangements to institutionalize health equity financing for the non-formally employed and works with labor ministries to capitalize the potential within social health insurance for the formally employed. Although there are a few examples of restructuring attempts in some of these areas underway, particularly in the area of public-private engagement in restructuring primary health care, they appear to be plagued by turf battles. There is a need therefore, to develop the right policy, procedural and ethical framework and to chart a direction for a concerted reform in the health sector, building further and gathering evidence from the efforts currently underway. Such a transformational change will require not just political will and drive but also astute technical knowledge, organizational capability and the courage to fight vested interest groups that always oppose change.
The writer is the founder of a think tank. E mail: sania@heartfile.org
The new government’s option
Published in The News International on December 31, 2007:
With the elections of 2008 forthcoming, and a change of hands on the governments reigns envisaged shortly, it is evident that any new government in Pakistan will have many issues to grapple with – from terrorism and conflict to the energy crisis and stalling fiscal indicators; inevitably and understandably, these will be the substrate of the new government’s focus as a result of which certain critical systemic issues are likely to get relegated to the background – issues that ultimately tangle most governments in a vicious spiral over the long term. Balance dictates that the new government must accord high priority to these issues right at the very outset. Foremost amongst these issues is the complex maze of malpractices and corruption, which in its truest sense cannot be extricated from governance challenges, mismanagement and inefficiencies. Within the framework of governance, these terms are often used interchangeably; the connotation of corruption makes it distinctive though as the other three may be inadvertent and without the intent to benefit whereas the nuance corruption has is one of deliberate and illegal gains. Notwithstanding the vague separating lines between these expressions, it is best to address them together as they have complex interdependencies.
As of now, the commitment of political contenders for public offices to address these issues is reflected in respective party manifestos, most of which have been published and launched; those in the public domain have been reviewed for their strength and potential as evidence of party positions to address the issue of corruption and related governance challenges. The assessment yields that most manifestos have alluded to corruption as a systemic issue – some directly whereas others as part of related issues. PML (N) and Tehrik-e-Insaf have sections on corruption whereas MQM and PPP refer to the phenomena as part of their respective sections on governance. PML (Q) has allocated two bulleted items each under Devolution and Diversity – two of their five-point agenda items whereas ANP refers to the subject under bullet 18 of its section, which focuses on ‘Structure of the state and the government’. Before going on to an analysis of these, it is acknowledged that many areas of broader structural reform within the ambit of local government, administration, police, labor, legislative and tax reforms in various manifestos also have a bearing on improving transparency and hence mitigating corruption. Notwithstanding, most of them now need to build significantly further on their manifestos to comprehensively address the range of malpractices that range from corruption in the administrative and operational domains to sinister patterns of state capture.
The former includes many forms of financial, moral, procedural and ethical malpractices in the delivery of publicly funded services, central regulatory functions, field inspection to ensure compliance with standards to corruption in contracting and procurements and malpractices in human resource hiring, placements and monitoring, as an outcome of which, state funds can be embezzled or pilfered and publicly funded services can get mis-targeted. On the other hand state capture is a broader phenomenon in policy and decision making where the laws and regulations of the land are made to favor a select few – usually cronies of the powerful with access to corridors of power.
Whereas the former is more easily amenable to structural reform, the latter is more deeply rooted in imbalances in institutional processes and is harder to fight. It is expected that political parties convey their positions on how they envisage addressing the former through interventions in the operational, administrative, technological and the civil service domains and the safeguards they envision building against state capture.
In state capture, an anticorruption agenda needs to go beyond the traditional technocratic approach focused on administrative reforms to a more overarching set of measures, which creates a number of policy and institutional imperatives.
Foremost, is the need for balance between the countervailing forces of the state – the judiciary, media, parliament and the civil society. This is a feat in itself since political parties sometimes have a vested interest in fostering an unbalanced act and in order to achieve this Herculean objective, reform of political institutions is needed as a starting point – a subject on which most manifestos are silent. Secondly, the core prerequisite for building safeguards against state capture also necessitates ensuring that certain key institutions are truly independent. Institutions such as the Public Accounts Committee, the Election Commission, the Provincial and Federal Public Service Commission, the National Accountability Bureau and the office of the Auditor General of Pakistan need to be adequately resourced and made to follow transparent procedures. Many manifestos have underscored commitments to ensure that one of these institutions, the National Accountability Bureau is not used as a tool for political exploitation and several others have referred to the need for appropriate leadership and transparency. However, only time will tell how these commitments cascade into action.
The other kind of malpractices referred to in the administrative and operational domains are relatively easier to counter through structured interventions in the administrative and services domain. Ironically it seems that many of these are individual coping strategies and represent economic responses to low incentives in the public system, which the private sector exploits for gains owing to limited oversight and accountability. Addressing these however, requires a firm commitment and a clear understanding and it is within the intent of bringing clarity to what is needed that the following points are articulated.
First is the issue of institutionalizing integrity in public service. Manifestos have referred to elements of the fall-out as a result of lack thereof and have additionally referred to some measures. However, a comprehensive range of measures are needed to structurally inculcate integrity in public service. Manifestos now need to be built upon further to enable political parties to develop their own positions on developing systems of compensation adequate to sustain appropriate livelihood, systems for transparent hiring and promotion, mechanisms to provide appropriate oversight of discretionary decision making and their own systems for strengthening the incentives-performance-accountability nexus. It is important to develop options in view of the work that has already been initialized in this area particularly with reference to the work of National Commission for Government Reform and other initiatives in the area.
Secondly, one of the most effective means of ensuring compliance with ethical and administrative codes of conduct and building safeguards against vested interest is by capitalizing technology for promoting transparency in management and tracking. Technology is the best tool for promoting transparency in governance. Electronic equipment and supply inventories can track leakages from the system, nationwide databases for matching staff and wage payments can maintain up-to-date records and can therefore assist in eliminating abuses such as paying ghost workers whereas electronic bidding can promote greater transparency and hence prevent collusion in contracting. In addition, maintaining information systems on price, quality, volume and performance of suppliers can enable tracking of leakages and discrepancies. Here again political parties need clear strategies and follow-up plans to build further and strengthen and/or bridge gaps with reference to efforts in the area currently under way. For example the e-government initiative, the Electronic Government Directorate and initiatives such as PIFRA, which is focused on improving financial reporting and auditing and of which procurement reforms centered on electronic bidding is one component.
Thirdly, it must be appreciated that one of the determinants of malpractices and corruption in the domain of oversight and regulation is the form of regulation itself. For decades the post-colonial imprint on Pakistan’s administrative systems has fostered a command and control style of regulation to ensure compliance with government-stipulated norms and standards. This inherently breeds corruption owing to discrepancies in systems of compensation vis-à-vis vulnerability of the controls to exploitation by vested interests groups. There is therefore a need for a fundamental shift in the style of regulation from the one currently prescribed to market harnessing methods that are third party-based using contracts and self regulation, which mitigate reliance and command and control to a large extent. Again as in the former cases, a number of initiatives presently on ground need to be reviewed carefully and party positions should clearly set forth their respective options for a way forward. The recently-reported success in taxation and police reforms need to be examined closely for lessons that could be extrapolated. Restructuring of social services in the area of health where the government is presently attempting to leverage non-state actors through contracting arrangements and other alternative service delivery models merit objective evaluation of their true potential. Likewise, evaluation of current initiatives to develop physical infrastructure leveraging the public-private interface should be the basis of respective political parties coming forward with their positions in this area, which has a bearing on many regulatory functions. We have also seen a number of new institutional entities or regulatory authorities emerge over the last decade on the premise that separating the policy-formulation and standard-setting functions of the state (entrusted to ministries) from the function of policy implementation (for which the regulatory agencies are mandated) can reduce conflict of interest and enhance efficiency. It is expected that contenders for public offices and their party bases would develop clear positions on this and articulate a way forward. The idea should be to create autonomous agencies at an arm’s distance from the government’s control in the absence of which regulatory agencies become just another tier in the government’s hierarchy.
In the fourth place, it is well known that economic reforms can be one of the most powerful anti-corruption strategies; by promoting competition and market entry, they can enable a vibrant sector of small and medium enterprise to weaken the concentration of economic interests promoting state capture. Here one expected to see the articulation of specific strategies in party manifestos as evidence of appropriate capacity in party ranks to offer solutions to steer Pakistan’s present growth into equitable and pro-poor growth.
From an institutional stand point several political parties have alluded to new commissions and institutional arrangements for addressing corruption. However, before that what is more important is a review of existing laws and institutions. In term of existing laws, it must be appreciated that the legal framework for dealing with corruption already existed even before the Ehtesab Ordinance, both in substantive and institutional terms. However it must be ensured that new laws do not dampen the spirit of existing anti-corruption efforts; in particular the National Reconciliation Ordinance has been a set back to anticorruption work in Pakistan, at least in spirit. Several institutions such as the National Accountability Bureau, established through the Ehtesab Ordinance 1996 and the Federal Investigation Agency (FIA) established under the Federal Investigation Agency Act, 1974, and the Wafaqi Mohtasib (Ombudsman) also exist. What is greatly required is the strengthening of the institutional framework as well as the implementation and application of the existing laws and procedures. Most importantly there is a need to build safeguards against using these institutions as tools of political exploitation.
Many parties have alluded to a commitment to strengthen these institutions. However in order to put this into practice, action beyond hand picking leadership will be required. The specific weaknesses of every agency mandated with accountability tasks will have to be assessed. For example, The Ombudsman’s office is a potentially robust institutional framework; similar institutional entities have been used most effectively for addressing injustices to individuals in many countries. One manifesto has outlined a commitment to develop Ombudsman’s offices in every district. As an ultimate objective this maybe a good idea; however before that it is important to address the Ombudsman’s mandate in Pakistan. Presently the institution is not mandated to deal with any action which falls within the purview of corruption – a weakness that significantly narrows its focus. Therefore in addition to broadening physical infrastructure, strategic empirical insights into prevailing impediments can lead to common sense restructuring solutions which can be both operationally sound as well as technically feasible.
As a nation we cannot afford to take the issue of malpractices and corruption lightly; Transparency International’s Global Corruption Barometer and its World Corruption Report of 2007 – both of them released this year as well as many other comparative country rankings originating from the World Bank, the World Economic Forum or other institutions point to the need to address this issue as do locally conducted evaluations by institutes such as PIDE and GALLUP. We in the social sector deem factors such as the setting of overall directions and management of public resources critical for being addressed, as without attention to these state funds will continue to be pilfered and publicly funded services will continue to get mis-targeted.
The manifestos therefore need significant follow up work to come up with solutions that enhance efficiency, effectiveness and equity and most importantly decrease malpractices in the current system. In doing so one would expect follow up strategies to be embedded in a contemporaneous context, positively critiquing, objectively analyzing and pragmatically looking at programs, strategies and instruments on the table to assess weaknesses and bridge gaps in area that have the promise of sustained impact. Clearly we are not starting a country de novo. The ultimate test, however will come in assessing the extent to which commitments reflected in manifestos are honored a few years down the line; it is hoped that this time round, they would fare better than what is evident from past records.
The author is the Founder President of a health think tank. E mail: sania@heartfile.org
Corruption: the need-greed equation
Published in The News International on December 09, 2007:
Pakistan’s ranking on the 7th position in the recently released Global Corruption Barometer by Transparency International should lend a serious impetus to address an issue, which is deeply ingrained in the institutional processes of the country, both in the public and private sectors and in many fiscal, ethical and moral shades. However it is important to recognize that corruption is not specific to Pakistan but is a systemic phenomenon, endemic to developing countries and prevalent in many in western nations. Corruption is also not a new occurrence in Pakistan but is a manifestation of a time long practice; this is evidenced by a reference made to the phenomenon by the Quaid on the occasion of his address to the Constituent Assembly of Pakistan on August 11, 1947. Corruption is also not a phenomenon for which a particular government can be blamed; notwithstanding, various governments have set precedence for ingraining different forms of corruption and have failed to pay due attention to the matter.
Corrupt behaviors fall on a spectrum and although it may be difficult to categorize them, it is useful to draw a distinction between the two forms of corruption from the point of view of the feasibility of anti-corruption reform in Pakistan. On one end of the spectrum are corrupt practices, which fall in the operational/administrative domains; most of these represent individual coping strategies and are relatively, more readily amenable to reform. At the other end of the spectrum, corruption involves a level of state capture, which is rooted in weak capacity of state institutions along with lack of control and accountability and vested economic interests of the powerful elite. The determinants of state capture are not amenable to reform within an isolated sector.
The first kind of corruption involves a variety of patterns in the operational, administrative and regulatory domains; these range from financial corruption in contracting and procurements where a huge margin exists for building in kickbacks to corruption in many regulatory domains; these include granting permissions, licenses and registrations and monitoring and inspections to ensure compliance with stipulated standards in the domains of quality, price and volume regulation. In these cases, commissions, bribes and deliberate inattention to oversight are endemic and clearly it is not just the public sector which is involved but also the private sector that fuels this practice. This form of corruption also includes the moral, procedural and financial forms of corruption in the delivery of services as in the case of the health, population and education sectors, where discretionary funds can be embezzled, inspectors may be deliberately inattentive to oversight and providers can get by through moonlighting in the private sector, pilfering state funds and charging costs for services that are meant to be provided by the state for free. There can be no condoning these practices, notwithstanding it must be appreciated that many of the above represent individual coping strategies and are economic responses to low incentives in the public system. When a public servant is not paid enough to pay for his utility bills and cover the cost of the children’s education, but at the same time has the discretionary authority which enables him to raise money elsewhere, it is only plausible that he will exercise that power. These practices are exacerbated by poor oversight and accountability and ultimately get institutionalized in the system, enabling most of the stakeholders to benefit from them in one way or the other.
There is evidence to show that corruption at this level can be addressed to some extent if attention is paid to three aspects of reform, which strengthens the incentives-performance-accountability nexus. Lessons learnt from police reforms in the federal capital can be instructive in this regard and show that where systems of compensation adequate to sustain appropriate livelihood are set up, and where services generate incentives for performance, it is possible to implement ethical and administrative codes of conduct. Such examples can be used as evidence to structure transparent systems of public service that safeguard accountability and can be strengthened further by mainstreaming technology. There is also the need to promote market harnessing methods in regulation using contracting and self regulation; these mitigate reliance on discretionary command and control mechanisms. Some level of success in this approach has been shown in the domain of taxation reforms and needs to be further build upon in other areas, particularly the social sector where governments can leverage markets to deliver services in new models of service delivery. The National Commission for Government Reform can be a good entry point for such reforms, albeit if the government has sustained policy support.
The other kind of corruption – much harder to fight is rooted in state capture, which is a broader phenomenon in policy and decision making, where the laws and regulations of the land are made to favor a select few – usually cronies of powerful with access to the corridors of power. In this form of corruption, decision makers use state resources and leverage for patronage either for personal or institutional gains. In addition to straightforward commissions on large transactions, this form of corruption also manifests itself as preferential treatment to well connected individuals. This form of corruption also overlaps with regulatory capture which results in regulation to be self serving.
Here an anticorruption agenda needs to go beyond the traditional technocratic approach focused on administrative reform to a more overarching set of measures to address many issues related to structural reform; this creates a number of policy and institutional imperatives. In the first place, it necessitates reform of political institutions and building mechanisms of oversight. Secondly there is need for judicial and prosecutorial reforms; within this context, the current emphasis to ensure an independent judiciary is well placed, however it must also be ensured that the judiciary is transparent in view of the evidence presented in Transparency International’s World Corruption Report of 2007, which focused on corruption in the judicial system. In the third place, there is a greater need to expand the use of consumer voice by creating avenues for seeking redress, rejuvenate the civil society and ensure that the media remains open. In addition it must also be recognized that economic reforms can be one of the most powerful anti-corruption strategies; by promoting competition and market entry, it can enable a vibrant sector of small and medium enterprise to weaken the concentration of economic interests promoting state capture.
In order to implement these approaches, Pakistan needs neither new statutes nor another set of institutional mechanisms. A number of federal and provincial laws exist, including the Ehtesab Ordinance 1996. What is greatly required is strengthening of the institutional framework as well as the implementation and application of the existing laws and procedures. However it must be ensured that new laws do not dampen the spirit of existing anti-corruption efforts; in particular the National Reconciliation Ordinance has been a set back to anticorruption work in Pakistan, at least in spirit.
Pakistan also does not need new institutional mechanisms to counter corruption. The Federal Investigation Agency (FIA) and the National Accountability Bureau exist and must be strengthened further and where needed depoliticized. The office of the Wafaqi Mohtasib, which is currently not mandated to deal with corruption but has a related role should be broadened and closer synergies created between institutional arrangements.
A focus on these arrangements would also enable redressing mis-governance, mismanagement and inefficiencies in addition to corruption as these are deeply inter-woven and failure to address them will continue to mis-target resources and compromise public investments, regardless of the level of economic growth and the increase in fiscal space.
We cannot afford to regard corruption taboo anymore. Patriotism does not entail shying away from core issues but addressing them through constructive criticism and helping develop and deploy solutions.
However garnering an unyielding commitment to this agenda in the wake of Pakistan geo-strategic vulnerability would be a feat – it would be interesting to note how many political parties commit them to this agenda in the forthcoming months.
The author is the founder president of the NGO Heartfile sania@heartfile.org
Integrating a new public health order
Nishtar S. Integrating a new public health order. Lancet 2007;370(9603):1901.
Time for a global partnership on Non-Communicable Diseases.
Nishtar S. Time for a global partnership on Non-Communicable Diseases. Lancet 2007;370(9603):1887-8.
Does corruption lurk in the health sector of Pakistan?
Published in The News International on August 05, 2007:
Transparency International’s World Corruption Report of 2007 with its focus on corruption in the judicial system is of contemporaneous relevance to Pakistan with respect to the spotlight on the judiciary. However, its findings have also opened a debate in many sectors in the country owing to its inclusion of Pakistan amongst the 37 countries studied and the sectoral comparative rankings. The interest in the area has also been further exacerbated by reports of two recently conducted surveys in Pakistan. According to the first, a perception survey of civil servants conducted by PIDE, 93% of the respondents think that performance of the civil services has deteriorated over the years. According to the second survey conducted by Gallup, 43% of the urbanites believe corruption is prevalent in the country.
Discussions relating to the health sector are never complete without references to malpractices which fall within the preview of fiscal and ethical corruption; even if half this anecdotal evidence is grounded in reality, the fiscal costs incurred to the state and the cost of accessing care – which remain undocumented – appear to be significant.
In recent years public sector allocations for financing health have significantly increased; however, corruption stands as a key impediment to the impact of well-intentioned spending on health. Without addressing this issue, the commitment to meet goals articulated in the Millennium Declaration as well as others embodied within indigenous policy instruments such as the MTDF simply cannot be met. It is for this reason that the government should accord high priority to the issue because of the potential it has to compromise public investments in a highly constrained environment. What should therefore be done in this regard?
As a starting point, there is a need to understand and prioritize corruption risks by corruption mapping and analyzing incentives and disincentives. This must be done at several domains.
The anecdotal reports of corruption in the pharmaceutical sector must receive careful and objective analysis. Corruption in this domain has a direct bearing on the performance of the health system. This practice can involve both the regulators and the private sector and may involve any step along the drug supply chain, starting from registration, licensing and accreditation to the setting of prices, marketing of drugs and sale and procurements. Corruption in this sector has its roots in the commercial interests of the non-bonafide pharmaceutical companies, who find compliance with regulations costly and try to bypass procedures to get their product registered, speed up the approval process, get favorable prices or to have their drugs included on the essential drug list in order to increase their market share.
The contracting process for the purchase of drugs offers a lucrative source of returns for corrupt officials and suppliers through kickbacks, over-invoicing, and outright graft. There is anecdotal evidence for the same in Pakistan from several public hospitals; however this needs to be assessed carefully and its magnitude quantified.
In the procurement process, common corrupt practices include collusion among bidders, kickbacks from suppliers and contractors to reduce competition and to influence the selection process, and bribes to public officials monitoring the winning contractor’s performance. Corrupt procurement officers can also purchase sub-standard drugs in place of quality medicines and pocket the difference in price.
It is also reported that varying quantities of drugs and medical supplies are stolen/pilfered from central stores of hospitals and individual facilities and are diverted for resale. This result – it could be speculated – is due to institutionalized corruption, which involves a variety of practices such as record falsification, dispensing drugs to ‘ghost patients’, graft and padding of bills, clever book keeping, overpayment for supplies, over-invoicing or simply pocketing the patient’s payment. Other forms of abuse, fraud and mismanagement can occur due to insufficient management and monitoring capacity; e.g. supplies do not meet expected standards, or they are only partially delivered or not delivered at all, or selling low quality, expired, counterfeit and harmful drugs at cheaper prices.
The process of licensing pharmacies or chemists’ shops can also be corrupted. However most important in the pharmaceuticals domain is the issue of aggressive drug marketing strategies, which can lead to the unethical promotion of medicines or to conflict of interest that influence physician’s judgments. Instances where physicians actually have financial/material incentives to prescribe certain drugs are also well described anecdotally. In Pakistan, more than 450 pharmaceutical companies manufacture almost 45,000 registered drugs. Such competition coupled with hospitality-based incentive-intense marketing can lead to unethical marketing practices, which have the potential to affect medical practice and treatment decisions of physicians. The ultimate outcome of all these practices are either higher price for purchased medicine and/or compromised quality. Patients are directly affected in this process as they are forced to supply their own medications.
The second area which should be carefully analyzed is staff absenteeism and dual job holding; this undermines service delivery and leads to closed/under utilized public health facilities; this in turn, conflicts with the equity and health objectives of publicly financed health care. In a minority of cases, absenteeism is unavoidable; for example, rural health workers often need to travel to larger towns to receive their payments, fetch supplies or drugs and are sometimes delayed by poor infrastructure. However, in most cases absences are frequently motivated by responsibilities at a second job. Other than absenteeism there are also other staffing issues that can undermine productivity at public health facilities through shaving off hours, late arrival and early departure, and frequent and long breaks. Absenteeism is symptomatic of ineffective management and translates into high cost for the public sector with little output; it also compromises the quality of health care across the board by relying on ill-trained providers or quacks for care.
The third area of assessment falls under the current restructuring arrangements at the primary health care level, where the administration of Basic Health Units (BHUs) and Rural Health Centers (RHCs) is being handed over to the private sector. Though a step in the right direction, an important caveat here is that this may open a potential avenue for lack of transparency in contracting arrangements, which flags a clear imperative for ensuring procedural clarity and transparency.
Corruption can also be ingrained at a regulatory level in the healthcare domain. Several regulatory can institutions form settings for such practices. Pakistan does not have an institutional mechanism for quality control, hospital accreditation or provider credentialing except for the Pakistan Medical and Dental Council, which serves the role of provider registration only. Pakistan is, however currently underway to establishing the National Drug Regulatory Authority. Experience from many developing countries suggest that if such regulatory institutions are created without awarding the right incentives to regulators and institutionalizing the right checks and balances then paradoxically they compromise the health system rather than strengthen it.
Furthermore corruption also needs to be quantified at the governance level particularly with reference to the losses incurred through the anecdotally reported kick-backs, pilferage, and embezzlement – a manifestation of a poor fiscal control over public funds. Other forms of intellectual and ethical corruption such as deliberate lack of over-sight, unfair hiring practices, in attention to staff accountability for misconduct and preferential treatment with connected individuals and basing priorities on political expediency and benefaction rather than evidence have also been reported. The magnitude and determinants of these needs to be quantified.
The assessment should guide strengthening of anti-corruption measures; which brings us to the action level.
Here is must be appreciated that corruption necessitates a mutually re-enforcing anti-corruption agenda; this is where the National Accountability Bureau can play strategic role – both in the investigative and preventive domains in light of section 33-B of the NA Ordinance of 1999. A number of next steps should logically follow.
First, is to ensure that laws are in placed to deter corruption. A range of legal instruments exist in Pakistan that makes corruption a punishable offence. However, new statutes representing a stronger commitment to eradicating corruption are also needed. It is true that laws have limitations in our environment owing to the limited capacity of enforcing agencies and true that anti-corruption work cannot be complete without enhancing institutional capacity. Notwithstanding, statues must still be the first step; ensuring that they are not open to interpretation and are not exploitable will aid their implementation. In addition, other laws such as freedom of information laws also need to be updated/developed.
Secondly, there is a need to review procurement and financial management policies in the health sector. A number of new regulatory institutions have been created to streamline public procurement such as PIPRA and a range of reforms have been institutionalized to streamline financial management and accounting systems. The guidance that these can offer to the health sector should be reviewed and leveraged. Policies should also be able to mitigate collusion in the procurement process.
Thirdly, the use of technology is being increasingly promoted in the health sector; however the most effective use is in the area of establishing systems that can enable and promote greater transparency. For example, electronic national health accounts promote greater transparency in health systems; electronic public expenditure tracking procedures and electronic equipment and supply inventories can track leakages from the system and a nation-wide database for matching staff and wage payments can maintain up-to-date personal records and therefore can assist in eliminating abuses such as paying ghost workers. In addition, drug procurement reforms centered on electronic bidding can promote greater transparency in the process of drug registration and pricing.
In the fourth place, Local regulations will have to be strengthened in line with the international code of marketing practises and should be strictly enforced as minimum requirements for the pharmaceutical industry and the medical community to comply with. Other measures should be promoted to check mushrooming of spurious drugs – an area which was significantly in the limelight a year ago with the suo moto action by the Chief Justice. Strict penalties should be implemented for violations of the law which make it possible for spurious drugs to gain access to the market such as fake licenses to sell, duplicate documents, absence of warranty of purchase of all products, gaps in the sale purchase record of all products, inadequate storage practices at outlets, and the absence of unqualified personnel at outlets.
In the fifth place, at a service delivery level, corruption can be countered by mainstreaming alternative modes of service delivery and financing. In autonomous hospitals this can be done by strengthening governance and bringing efficient management that is given true administrative and fiscal controls. Service delivery reforms at the basic health care level can increase accountability through management devolution/contracting out and by giving greater fiscal and administrative autonomy. In such arrangements institutional incentives such as the ability to hire and fire the staff and authority to reward performance and discipline, transfer and terminate employees who engage in abuses and the ability to audit can also help counter corruption. With reference to the practice of quackery, coercive regulation is unlikely to be effective and therefore decisions to curb these practices have to be pragmatic and feasible such as by developing approaches to mainstream their role into the delivery of care by accrediting them to provide some services. However, an anticorruption agenda at a health systems level is complex and warrants health system reconfiguration; this goes beyond incentives and has to do with health systems’ reforms in a broader sense.
A comprehensive anticorruption agenda in the health sector also has to scope much further than what has been stated and has to take into account other overarching issues such as remuneration of public servants through civil and public service reforms – which is the mandate of the national Commission on Government Reform. In addition there is also the need to create operational linkages of the National Accountability Bureau with the health sector.
In a nutshell therefore, healthcare provision depends on a system which efficiently combines financial and human resources and supplies to deliver services; good governance and transparency are critical factors in making such a system function.
However on the other hand, both poor governance and corruption in the health system are manifestations of a broader systems phenomenon in a country. Addressing these issues requires mandates and prerogatives both within but also outside of the health sector, which is why ideally, an anticorruption drive in health must ride a much larger wave.
The author is the founder president of the NGO Heartfile sania@heartfile.org
Disease Diplomacy
Published in The News International on July 01, 2007:
For most of us, disease pandemics are forgone history; plague killed 12 million people in 1855, but we think of it just as a setting in Jean Plaidy’s novels. Influenza claimed 25 million lives in 1918, but it is just through references in written accounts that we know of that. Much as we would like to disbelieve it, we may, unfortunately, not be far from another infectious disease pandemic given that the imprints SAARS and Avian flu have left in epidemic outbreaks have many bearings, which can herald a pandemic. If that happens, in this day and age of global communication and travel, more than 60 million people can die worldwide – majority of these in high population developing countries such as ours.
Emerging and reemerging infections are therefore, the foremost threats to global health security with the potential to create catastrophic damage; however these are not the only threats. Public health emergencies of national and international concern can be nuclear, biological or chemical in nature – terrorism related or accidental. The Chernobyl disaster and the anthrax scare being cases in point. Though conventionally, natural disasters are not classified as threatening ‘global health security’, they too can cause devastation of similar scale and warrant institutional responses, which can be combined for disaster preparedness.
Despite these realities, health has never been a big ticket item in discussions of national interest – and if one contemporaneous event has changed that by demonstrating the potential that health has to incur ‘economic losses’, then it would be the SAARS and Avian influenza epidemics, both of which led to serious social, economic and political consequences. The unprecedented losses that both these outbreaks caused in a number of countries, enabled health to achieve the highest political profile whereas the transnational spread of these diseases challenged the limits of state sovereignty and redefined national responsibilities. Billions of dollars were lost by countries in the tourism, hospitality and transport industry. International trade and travel almost ceased, markets went into slide, economies were crippled and public health systems buckled. High levels of the governments got deeply involved and perhaps for the first time, a global multisectoral response in many countries was galvanized into action in an attempt to exploring ways of speedily ending the epidemic. Never before in the history had the media been so involved in a public health emergency. However, it must be noted that both SAARS as well as the Avian influenza erupted in epidemic proportions (sudden increase in the number of cases in a period of time); mankind was lucky this time round! Some characteristics of the SAARS virus made containment possible. Infected individuals usually did not transmit the virus until several days after symptoms began and most were infectious only by the 10th day or so of the illness when they developed symptoms. Therefore, effective isolation was enough to control spread this time round. If cases were infectious before symptoms appeared or if asymptomatic cases transmitted the virus, the disease would have been more difficult, perhaps even impossible to control – and a pandemic (epidemic outbreak spreading across a large region, world wide) could have been inevitable.
Of course there is no way of knowing what will come next, neither the timing nor the severity of the next pandemic can be predicted. However, the probability that a pandemic may occur has certainly increased. Understanding the role of migratory birds and viruses also leads us to believe that the risk of a pandemic influenza is serious. With the H5 N1 virus now firmly entrenched in large parts of Asia, the risk that more human cases will occur will persist. Each initial human case gives the virus an opportunity to improve its transmissibility in humans and thus develop into a pandemic strain. The only safeguard at this point with reference to preparedness is to ensure that we are better prepared than we were, when SAARS was unleashed.
The international public health community has not been silent to these realities. Invoking its constitutional prerogative to develop legally binding international regulations, the World Health Organization – the only agency with a globally embracing regulatory health mandate – has developed the revised International Health Regulations 2005 (IHR 2005); these came into force this week on June 15, 2007 marking a public health milestone and are the world’s first legally binding agreement in the fight against public health emergencies of international concern. International Health Regulations 2005 are an update of the International Health Regulations of 1969, which focused on cholera, plague and yellow-fever. The revision was needed to address limitations in the International Health Regulations of 1969 given that in recent decades cross-border travel, trade, communication and technology has developed markedly and new challenges have arisen in the control of emerging and re-emerging infections. In addition to all diseases of international concern, the updated regulations also address all threats associated with acute chemical or radio-nuclear origin. WHO has termed IHR 2005 as the ‘pillar of global health security’ envisaging that this will enable building and reinforcing effective mechanisms for disease outbreak, alert and response at national and international levels; additionally WHO also regards it essential that every country fully implements these regulations.
All 193 member states of the World Health Organization have agreed in principle to the revised regulations. However as part of its stipulations, countries are expected to build institutional capacity to strengthen global public health security and management systems for addressing public health emergencies and risks of international concern.
Pakistan has in place some measures to comply with international health regulations; these include public health infrastructure for surveillance at ports, air ports and ground crossings and an Integrated Disease Surveillance Plan. However, these suffer from several limitations. Furthermore, there are renewed responsibilities of governments under IHR 2005. These include setting up early warning components of national surveillance, public health actions at points of entry and responsibilities of national and international health focal points. Specifically, under these regulations, countries are expected to nominate international health focal points and mandate them with the task of notifying all events that may constitute public health emergencies of international concern and not just diseases. These focal points would be expected to communicate detailed public health information to WHO including case definitions, lab results, number of cases and deaths and conditions affecting the spread of disease in case of an epidemic. Pakistan has designated the focal point role to the National Institute for Health (NIH) in Islamabad. However the focal points are now expected to play the roles assigned to them and it is here that their several limitations need to be addressed as a priority.
Augmenting diagnostic and technical human resource capabilities within the Epidemic Investigation Cell of the National Institute of Health would be a critical first step. The recent Dengue outbreak outlined a number of weaknesses in the resource level and capacity; it is important to use evidence from lessons learnt to bridge gaps. In addition, information collection and analysis functions need to be strengthened at the District level; in terms of capacity building, existing initiatives such as the Field Epidemiology and Laboratory Training Program should be leveraged. It is also important to use technology to bridge the currently unacceptable delays in information relay through the Health Management and Information System (HMIS).
In addition, the existing infectious diseases surveillance systems need more resource inputs to bridge gaps. These systems do not capture data from all sources – the private sector in particular. In addition, there is limited capacity to confirm clinically diagnosed cases of reportable diseases because a functional laboratory system does not exist outside of urban areas. Limited capacity is compounded by gaps in legal requirements to report notifiable diseases. Therefore in addition strengthening surveillance, legal and policy requirements that can mandate the notification of priority diseases and regulation of laboratory practices should also merit attention. Effective surveillance is also particularly important in Pakistan because illnesses with similar initial manifestations (malaria, influenza, typhoid fever, hepatitis) are common in the country; surveillance protocols should take this locally reality into account.
To assist the implementation of the IHR 2005, WHO has created the Global Alert and Response Network – a technical collaboration of the existing institutions and networks coordinated by WHO that can pull technical and human resources for the rapid identification, confirmation and response to outbreaks of international importance. For countries such as Pakistan with limited capacity, it would be important to create active linkages with this initiative and to assess how this resource can be tapped into.
It would also be important to create linkages between the IHR focal points and other institutional arrangements relevant to ’emergency response’, which are currently being housed under the Earthquake Rehabilitation Authority, in the aftermath of the October 8, 2005 earthquake. Both these should ideally be reconfigured as a Health Incident Management System in Pakistan – a system which incorporates disaster planning within its realm with a focus on preparedness, response, and recovery. Such an institutional entity should foster collective responsibility to complex and unique emergencies – natural or manmade.
The context of the October 8, earthquake tragedy has an additional important relevance here. In the aftermath of the earthquake, Pakistan received considerable international assistance. However it must be appreciated that in pandemics other countries are also likely to experience emergency conditions, and therefore, opportunities for inter-country assistance such as those seen during the October 8 earthquake or local disease outbreaks may be curtailed. This is precisely why reliance on indigenous capacity is a prerequisite.
Another caveat here relates to the supply of medicines. It is now well established that the world has very limited supply of anti-viral medication; and not just that, global capacity to produce these medicines is also constrained. At the present manufacturing capacity, which has recently quadrupled, it will take about a decade to produce enough anti-viral medicines to treat 20% of the world’s population. Mathematical modeling has shown that the use of these drugs near the start of the endemic can reduce the risk of transmission; therefore the World Health Organization is currently stockpiling anti-viral medication. It is important that the government of Pakistan should think in terms of earmarking resources for procuring anti-viral drugs and placing its orders in the pipeline.
Contemporaneous challenges related to global health security are a downside of globalization. The world community now expects accurate, complete and timely information about diseases and events that threaten global health security and effective action to control them. Pakistan must comply with its international obligations. The budget of 2007-08 earmarks Rs. 100,000 million for the surveillance of these diseases; it would be critical to use this budget strategically to build infrastructure that is both sustainable and effective.
The author is the founder present of Heartfile and Pakistan’s Health Policy Thinktank. E mail sania@heartfile.org
Health and the budget 2007 – How healthy is our budget?
Published in The News International on June 10, 2007:
The federal budget for 2007 will be presented on June the 9th, subsequent to which a special parliamentary session will be convened to debate the budget. Within this context, this article focuses on budgetary allocations for the health sector with a focus on four areas: aggregate level of allocations, quality of expenditures, allocation distributions and the issue of leakages and pilferage from the system, with a view to lending impetus to a dialogue on the short and long term imperatives of allocations in the health sector.
At the outset, it must be recognized that a discussion on budgetary allocations for health is important for a specific reason. Health is fundamental to the social sector and in countries where macro policy decisions are largely shaped by geopolitical realities and market forces, allocations for the social sector are a true reflection of any government’s commitment to meet the equity objective.
First, with respect to total allocations, it is well recognized that there have been unprecedented increases in budgetary allocations in recent years; the forthcoming allocation of Rs. 13 billion is a positive development, indeed. However, even as it currently stands, public sector spending on health amounts to roughly US $ 4 per capita after adjustment for population growth and inflation. There is, therefore, still a wide gap to be bridged between this and the internationally recommended public sector spending of US $ 34 per capita – a level at which the delivery of a package of essential health services to populations becomes possible. In other words, it would then become possible to achieve goals such as the MDGs and others articulated in the MTDF. Theoretically, this would necessitate a five-fold increase of the existing budget or a 50% increase every year for the next 10 years. Pakistan’s Fiscal Responsibility Act does not stipulate such an increase. As a first step, therefore, we must set a 5-10 year plan for gradual but substantial increases in the health budget. Here it is important to address the next question: even if we achieve this impossible fiscal target within the existing health system, would we have the ultimate cure for our health woes? The answer is clearly a ‘No’ because of issues inherent to utilization capacity, an important indicator of which is the allocation versus expenditure lag. Budgetary lapses in the social sector are ascribed to lack of utilization capacity; this connotation masks systems challenges, which make the utilization of budgets challenging – excessive centralization of operational decision-making, onerous financial and administrative procedures and lack of accountability for delays in decision making, which have implications for fund flows are to mention a few. Coupled with this is limited capacity to plan and implement, which further negatively impacts the limited ability to expend. Therefore, alongside budgetary increases in aggregate and in program-specific categories, it is critical to set aside dedicated funds for procedural reforms.
Linked to this is the issue of quality of expenditure and expenditure targeting. A careful tracking of fund flows in the health sector shows a predominance of expenditures in the month of May and June before the financial year ends. In addition, there are no mechanisms in place to evaluate the impact of given allocations on outcomes vis-à-vis the equity objective and the poverty reduction strategy focus, which should be the core objective of the state health sector. Enhancing quality and appropriate targeting of expenditures is closely linked with governance, which creates yet another imperative for dedicated budgetary allocations to strengthen governance structures that enable the delivery of programs. A core prerequisite for sound governance is reliance on timely and appropriate information for decision-making. Again, this flags the need to provide substantial budgetary support to bridge the current gap in Pakistan’s health information system. There are several components of a health information system already in place, albeit with many gaps; however, there are also clear opportunities where the right investments in structures and technology in particular can enhance connectivity in the existing health management information system; enable building infrastructure for hospital information systems both in the public and private sectors; improve death registration and enhance the potential within existing survey instruments. It would be logical to make investments in these areas where gains can be achievable in the short term. This would require enhanced allocations over and above what has been currently budgeted for the National Plan for Disease Surveillance and the National Health Information Resource Center; reliable sources indicate that this amounts to Rs. 10 million and Rs. 28 million respectively. Additionally it is important to earmark funds for policy research, at least in areas where contemporary evidence is badly needed such as in the case of the post WTO impact on prices of drugs and the impact of WHO’ International Health Regulations 2007 at a country level.
The third area, which must form the substrate for the budget debate is the distribution of allocations in the budget of 2007. With reference to allocations within preventive health domains, a careful analysis reiterates the need to enhance allocations in certain areas. According to reliable sources, the health budget allocates 500 million each for blindness, maternal and child health and hepatitis; 350 million for HIV/AIDS, 100 million for malaria, and 205 million for tuberculosis. As opposed to this, only 5 million have been allocated for the prevention and control of non-communicable diseases (high blood pressure, diabetes, heart diseases and stroke).
It would be important to look at these distributions in the light of contemporary evidence on mortality (deaths) and morbidity (disease). The Burden of Disease Studies conducted to date by the World Bank and US-based academic institutions show that both communicable and non-communicable diseases (NCDs) share an equal burden in terms of morbidity. In terms of mortality, data from the Pakistan Demographic Survey of the Federal Bureau of Statistics show that the percentage of deaths attributed to NCDs has increased from 34.1% in 1992 to 54.9% in 2003. Critics argue about the validity of the Pakistan Demographic Survey data and refer to issues inherent to the validity, and accuracy of these statistics. But does it make sense to disregard local data completely, particularly when global trends and independent international evaluations also validate the same trends? Critics also argue that these diseases are not part of the MDGs; however, even if the MDGs are taken as a yardstick, we must be reminded of the fact that Goal 6 refers to the ‘other disease categories’ on the premise that countries would have the indigenous capacity to determine what constitutes a locally-suited priority. Non-communicable diseases should clearly be a public health priority, given that they kill more people than malaria, tuberculosis and HIV/AIDS combined. The point is not to question the validity of investments in these areas but to argue for increased investments for NCDs in addition. NCDs are equally important and merit due attention.
To date, the prevention and control of NCDs has been addressed through a very small program at the Ministry of Health, which is supported technically through the pro-bono contributions of an NGO and the partnership of professional associations. However, it is time for the Ministry of Health to develop a full program on NCDs.
Turning now to infrastructure in the distribution of allocations domain: there has been news of allocations for 900 (803) proposed heath care centers in the urban settings on the premise that these would decrease the workload burden on existing tertiary care hospital sites. This warrants revisiting a fundamental question in health which relates to the role of the state in health? The state should clearly be a ‘financier’ and ‘regulator’ of services; however, it need not be a ‘provider’ of services. Lessons learnt from the lack of sustainability and failure of the BHU initiative launched in the 1980’s should be instructive in this regard. This experience indicates that it might be best for the state to stay away from being a provider of services and focus on creating structures, which enable it to leverage the outreach of the private sector to deliver services. True that options for revitalizing existing state-owned healthcare infrastructure must be explored as in the case of the BHU restructuring arrangements given that something has to be done with the ‘existing’ infrastructure; notwithstanding, ‘future investments’ in infrastructure should weigh the benefits of ‘government provision of services’ vis-à-vis ‘government financed private provision’; the latter appears more plausible in a country where the law of the land lets the private sector operate. The same argument applies to another area in the current budget. The federal government will be paying for a tertiary care facility in NWFP, the annual recurring cost of which could enable the government to purchase services from market to achieve the equity objective. These options reiterate the need to revisit some fundamental policy standpoints – continuing to make investments in infrastructure vis-à-vis exploring alternative modes of financing, which can make service delivery more equitable.
Last but not the least is the issue of leakages from the system – an outcome of various forms of financial and moral corruption. There is anecdotal evidence of various practices, which lead to leakages from the system – kickbacks, over-invoicing, and outright graft in the contracting process, collusion among bidders in the procurement process and theft from central stores in hospitals are to mention a few. These occur as a result of poorly managed expenditure systems and poor fiscal controls over flow of public funds. Improving governance is critical to addressing these issues; from the budgetary standpoint, however, allocations in certain areas can give quick dividends. For example, electronic public expenditure tracking procedures and electronic equipment and supply inventories can track leakages from the system and a nationwide database for matching staff and wage payments can maintain up-to-date personal records and as such can assist in eliminating abuses such as paying ghost workers. Budgetary allocations should therefore leverage technology to enhance efficiency and promote greater transparency in health systems and to eliminate wastage of scarce resource, which lead to poor quality of care, compromised safety and efficiency and de-motivation of the staff.
To summarize, the budgetary increase this time around is commendable. However, as a short-term measure it is also important to reanalyze priorities for allocation and pay attention to systems strengthening with the understanding that these investments will not be visible for a while – quite unlike physical infrastructure. Over the long term, strategic planning exercises in the Ministry of Health, the Planning Commission and civil society think-tanks should focus on the following from a budgetary perspective:
Firstly, an essential package of health services should be carefully costed; the government should then make a five-year plan to enhance allocations to a level where the delivery of these services becomes possible. Simultaneously, they should also enhance their capacity to utilize funds, both through procedural as well as personnel reforms. Secondly, they should look carefully into policy and strategic directions both for the provision of essential health services for all citizens as a public good as well as other services for the under privileged who are not covered under any pre-payment scheme. In this connection, they should clearly articulate a policy on infrastructure vis-à-vis provision through the market and in the event of the latter, aim for the creation of an enabling and transparent regulatory environment. Thirdly, they should analyze alternative means of health financing by leveraging the potential within existing arrangements – mainstreaming safety net resources for health and insurance-based arrangements.
As the Parliament gets into session to debate the budget for 2007, they must be mindful of the fact that it is not enough to put money in programs; unless the systems to deliver them are reconfigured and strengthened, programs will never deliver on objectives.
The author is the founder present of Heartfile and Pakistan’s Health Policy Thinktank. E mail sania@heartfile.org
What is the role of the state in health?
Published in The News International on February 25, 2007:
The recent divide of opinion about the construction of the medical tower in Islamabad, the indication that another is in the pipeline for Karachi, signaling of investments underway in high-tech equipment, the organ transplantation bill and concerns expressed subsequent to its tabling and the debate around the much-hyped medical tourism raise two important contemporaneous questions about the role of the state in the health sector in Pakistan. First: what is the role of the state agencies with respect to ‘health’ within a ‘social sector context’? And second: what is the role of state agencies with reference to the emergence of health as a ‘sector’ within a ‘market economy’ in Pakistan? These two dimensions of health may seem interlinked, but they are, for all practical purposes, separate paradigms and warrant specific lines of planning and implementing arrangements and therefore the need for clarity at strategic and operational levels.
In a nutshell, the first question links with the Alma Ata ethos, the Health for All strategy, the charters of Ottawa and the Bangkok – Pakistan is a signatory to all; in line with these, it places health as an essential prerequisite as well as an outcome of sound development policies. The answer to the first question is also embedded in the ‘spirit’ of Pakistan’s commitment to meeting the Millennium Development Goals and reflected in Pakistan’s strategy papers – the Poverty Reduction Strategy Paper, Medium Term Development Framework and the current Health Policy of 2001, weaknesses notwithstanding. Extricating the answer to question one by these parameters, it is clear that that it has to be embedded in reducing mortality and morbidity and the disparities therein and striving to attain a good standard of health by all people in Pakistan. What is the role of state agencies in this context then? Foremost, it is to set the vision for the sector within the Constitutional framework of rights and privileges, values and principles and integrate the public and private sectors to deliver that vision. Operationally, this would entail a two-fold exercise.
First, and ideally it would be to deliver health services as a public good to the people of the country; pragmatically, however in resource challenged countries it is not possible to deliver all health services to all citizens and therefore the role of the state in countries such as in Pakistan is to outline a range of services it will deliver as a public good – what might be termed as the national essential health package. In the delivery of these services, the state needs to be clear about the coverage and the choices concerning those services, and most importantly, the means of their provision and the mechanisms. State agencies in health also need to deliver all services not classed in the above category to the segment of its population classed under article 38 of the Constitution through social protection measures. Both these objectives can be pursued in Pakistan by modernizing the public financing and provision of health services in order to make them efficient, effective, responsive and accountable so that they can provide the bulk of care through their own infrastructure or by leveraging the infrastructure of the private sector. This should underpin the creation of a National Health Care System in Pakistan and this is primarily the foremost role of the state in the health.
True that there is a private sector dimension to this role under Question One – and one that needs to be separated from what will be discussed under the second question. Here the private sector assumes importance as it can assist and augment the state’s health delivery agenda. For example, as in the case of using private clinics and NGOs to get essential services delivered, and involving the civil society, in strategic planning, in autonomous governance arrangements (as in the case of hospitals) and ‘contracting out’ management. Within this framework, the role of the state should be one of legitimate regulation, creating an enabling environment and developing the appropriate systems and procedures for public-private engagement with attention to safeguards. This calls for enhancing the capacity of state agencies for playing a contemporaneously appropriate and effective stewardship and governance role in the health sector.
The other role of the state under Question One is quality assurance of private sector health care through regulation. The private sector in Pakistan is huge and has many well documented problems with quality. It is the government’s duty to facilitate the private sector in general and this holds true for the health sector as well. However, the government also has a fiduciary responsibility in this regard given that health is one of the social services. Therefore, the key challenge is to foster, promote and strengthen private sector healthcare delivery and balance it against quality and patient safety while safeguarding the interests of the poor and the marginalized. With respect to the role of the state therefore, this underscores the need to address two issues. The first relates to quality assurance and links in with the need to create a regulatory mechanism for quality such as a national institute of health care quality. The other relates to developing means of using public funding to ensure that poor people who access health services through private providers are not disadvantaged or discriminated against. This in turn relates to factoring in waiver and exemptions in the existing social protection mechanisms at the level of private providers.
The second question is related to the role of the state agencies with reference to the emergence of health as a ‘sector’ within a ‘market economy’? Here ‘private’ has a ‘commercial connotation’; by way of contextualizing the subsequent discussion, it may be opportune to point out here that the healthcare industry is the world’s largest industry with global revenues estimated at US$ 2.8 trillion. Perhaps it is the largest industry in Pakistan as well. In this context, there are a number of considerations worthy of merit.
First, the much talked about ‘medical tourism’ which can present an opportunity for hospitals to fuel growth by tapping the potential of the international patient market. In relation to the role of the state foremost, an important caveat here is that public resources earmarked for health should not be used to promote medical tourism at the cost of essential health services as there is little benefit to serving the equity objective in health except indirectly through improvements in quality. However as this is an industry, the private sector should be encouraged to analyze opportunities, spearhead sectoral development and formulate strategies to improve their competitiveness. In this context however, the level of facilitation by the state should be guided by the potential that medical tourism holds in Pakistan with reference to fueling growth. A careful analysis shows that medical tourism has limited potential in Pakistan for a number of reasons. The success of medical tourism depends on many factors: high degree of sophistication of indigenous health systems, high quality of health care at low costs, an expatriate-friendly environment and a well developed tourist industry being the foremost; based on these criteria it is clear that the medical tourism industry would not have an emerging trend in Pakistan at least in the short to medium term. On the other hand, Pakistan is unfortunately being ranked amongst the few countries where transplant related-tourism is burgeoning – an issue brought increasingly to the limelight recently in the aftermath of the tabling of the organ transplant legislation. What would be the role of the state in this situation? Cleary, it is to build ethical safeguards through policy and legislative measures and their effective implementation so as to curb the existing unfortunate practices, which have been propelled by huge vested interests.
The second area of note is the post WTO-agreement on liberalization of services. Pakistan is a member of the World Trade Organization and signatory to the Agreement on Trade in Services (GATS); under this, member countries agree to make services trade more open to other countries with the essential aim of further liberalizing services that have traditionally been under the public domain. The main concerns with GATS have been along the lines of concentrated ownership and concerns about some rules that affect the ability of the government to hold companies providing these services, accountable. In addition mainstreaming of curative services on free market principles and the promotion of high-end care would be at the cost of prevention in which the private sector has no incentive to invest in any case. In the wake of these potential challenges, the government must enhance its own regulatory capacity to look at these contemporaneous globalization-related issues as they impact the delivery of health services.
The third area where market mechanisms cross cut with health is in the area of the export of generic drugs. Pakistan has a fairly large local pharmaceuticals manufacturing industry and growth of the sector as an industry in the neighboring countries raises the question of how we can enhance our revenues and pursue export targets by strengthening this industrial base. In the post-TRIPS scenario, with stronger patent protection, governments are under obligation to enhance research and development base of the local industry and the question of how this can enhance the above mentioned objective becomes even more important. Here it must be recognized that manufacturing and export is dependent on the economic policy framework, patent regime and other regulatory arrangements in a country and that a range of actors in the state’s system outside of health such as trade, investment, intellectual property rights and consumer protection have a role in this area. However at the same time, it must also be recognized that pharmaceuticals is one of the critical inputs into the health system and that the foremost role of state agencies mandated with a role in health is to ensuring the sustainable supply of quality, efficacious and safe drugs in health systems. What is the overarching role of the state here then? It is to bring clarity in agency roles, responsibilities and prerogatives in relation to pharmaceuticals as a critical input to health systems vis-à-vis pharmaceuticals pursued as an export target.
The fourth area is that of institutional-based private practice; there have been many attempts in various parts of the country aimed at mainstreaming this approach on the premise that this will enhance institutional efficiency; some of these have been successful as in the case of Punjab Institute of Cardiology whereas others such as in the case of NWFP have been unsuccessful for reason that are beyond the scope of this discussion. Increasingly, many a times a case is made for the use of public money earmarked for health on tertiary care infrastructure on the premise that it promotes institutional-based private practice. In this regard, the role of state agencies is to ensure that such investments are made only if they can improve performance and efficiency to meet the equity objective in health.
Finally, another commercial consideration in health is one of private health insurance – questions relating to its potential in Pakistan have frequently emerged. Here it should be recognized that private health insurance is just one of insurance arrangements in health and that its growth is generally paralleled with economic growth in general and growth of the formal employment sector where employers subscribe to health benefits. Through the current FDI policy of the government of Pakistan and the Insurance Ordinance 2000, an enabling environment has been created for the insurance industry in general; however, the health sector cannot benefit from this significantly because of a number of limitations: fragmentation of the provider market and the predominance of the workforce in the non-formally employed sector being foremost. As a result of this, health management agencies do not find the incentive to operate in the country. This is evidenced by the current situation – group health insurance is offered by seven insurance companies and individual health insurance by only one company, which is Allianz-EFU. In this context therefore, while the state can pursue measures to give financial incentives, albeit with safeguards to regulate practices of private health insurance agencies, this should be with the realization that many other factors influence the growth of private health insurance. There is an important caveat here: easing of insurance regulations and opening up of the sector should be on the premise that the formally employed private sector will subscribe to this and clearly with the understanding that is not a substitute for the states role in financing health.
In summary therefore, health should be regarded as a fundamental human right and a key component of the social sector. In this era of liberalization however, the health sector also cross-cuts with the market mechanism in many areas and stands out as an industry.
As the magic of the market creates opportunities to enhance efficiencies in the health sector in Pakistan with the indirect possibility of the under privileged benefiting, the state needs to be cognizant of the potential that these have to create inequities and must regard its responsibility for social welfare as a priority to bridge them.
The author is the founder present of Heartfile and Pakistan’s Health Policy Thinktank. E mail sania@heartfile.org
Community health promotion – a step further.
Nishtar S. Community health promotion – a step further. Promot Educ. 2007;14(2):61-2, 109-10, 124-5.
Social Policy Reform – raison d etre
Published in The News International on January 30, 2007:
Social policy is central to politics and one of the major responsibilities of governments. In many developed countries the entire political debate is structured around social guarantees that representative political contenders can offer to their electorate and subsequently, sustained access to the corridors of power determined by how the agenda is delivered. How does Pakistan fare in terms of delivering social services, is a question which needs to be addressed with clarity. This article outlines the rationale for developing a comprehensive social policy, within a social justice framework in view of the recent reshaping of the role of the state and the manner in which the government does business; attempts to explain where Pakistan stands in terms of the delivery of social services, and presents a viewpoint in an effort to lend impetus to the creation of a vision for social policy reform within the country.
Why does the debate around a social policy assume importance contemporaneously in the first place? Pakistan has been experiencing economic growth which has created, both, the fiscal space and the expectation that the state will deliver on a social agenda. The current government has an economic policy, which in line with broader changes in the macro-economy, makes private sector the engine of growth on the premise that the role of the State is to provide a policy, regulatory and legal environment. True that flexible and fair market mechanisms lead to high levels of employment and therefore opportunities for the disadvantaged. And correct that a market economy assists in efficiencies and opportunities with the indirect possibility of the underprivileged benefiting; but the same is also known to be the source of major inequalities. A sound social policy can remove or mitigate social inequities created by the market system and is essentially the state’s instrument, which enables it to intervene to ensure that inequalities, inequities and deprivations caused by the market are remedied – or at least to some extent.
This brings us to the second question of whether Pakistan has a social policy?
In terms of standalone National Policies on Housing, Labour Protection, Health and Education – yes. However, Pakistan does not have an overarching social policy embodied within a social justice framework, which articulates Pakistan’s definition of social services, the choices concerning those services, their range and most importantly, the means of their provision and the mechanisms of their financing.
Those in the establishment can argue against the aforementioned argument ‘Pakistan does not have a social policy’ by referring to the recently launched Social Protection Strategy of the Ministry of Social Welfare, stating that the government’s obligation to chart a social policy has been fulfilled. However, this would be true to a limited extent; the Strategy is focused on ‘supporting vulnerable households in managing hazards and risks threatening their living standards, and facilitating necessary investment in human capital and physical assets that strengthen their resilience through a range of programs and policies’ and is, as such, aimed at benefiting the poor. Agreed that some of the original motivation for the expansion of welfare services should be to help the poor, but then it is now well established that many of the social services also benefit the middle classes; additionally, evidence has shown that anti-poverty policies have their limitations in reducing unjust social disparities and therefore action beyond poverty eradication is fully justified in a social services model. It therefore must be recognized that social protection is a concept embodied within a social policy, but it is not a substitute for it and the latter is clearly more overarching.
Generating a debate around the need to have an overarching social policy is not something along which work needs to start de novo in Pakistan since a vision can build on and link in with initiatives underway. Weaknesses notwithstanding, successive governments over the last 59 years should take the credit of creating both institutions such as the Bait-ul-Maal and the Employees Social Security Institution and initiatives which fall within the rubric of social services. The latter enable cash transfers as part of labour welfare schemes under Welfare Fund, Worker Profit Participation Fund, Employee Social Security Institutions, Employee Old Age Benefits, etc. In addition, various subsidies and feeding programs such as the Tawana Pakistan Programme are also social welfare/protection measures as are the state’s expenditure on health and education; the myriad of poverty alleviation programs within the framework of the Khushaal Pakistan program and the recent signaling of enhancing allocations embodied within the Fiscal Responsibility Act of 2005 also fall within the ambit. However, as already stated an overarching framework which conveys the government position on the means of their provision, the range across the short and long term, and a vision for funding services does not exist; in addition there are systems-level issues at the governance and implementation levels, which constrain the ability of many of these programs to deliver on stipulated targets. An overview of the social sector targets embodied within the Medium Term Development Framework and the Poverty Reduction Strategy Paper of the Government of Pakistan and Pakistan’s commitments to meeting the MDGs warrant a reinvigorated approach to meeting stipulated social sector targets – and one that will enable quantum leaps.
What are the options for a way forward to bridge existing gaps; can Pakistan be a welfare state? One model of delivering social services is closely linked to the concept of a welfare state, which is built on the concept of universalism: in other words on the principle that everyone should have access to a minimum level of service. In such a setting, the major responsibility of the state is to raise resources to pay for welfare on the one hand whereas on the other, the government’s administrative apparatus processes payments to millions of citizens based on eligibility rules for unemployment and social security benefits; these entitlements are often embodied in law as is the case in the United Kingdom and in many Scandinavian countries. Pakistan is clearly not a welfare state and under the present circumstances, it is definitely also not a feasible option to pursue this as an objective in the short to medium term. It must be recognized that a welfare state model can be adopted only by high income countries with a broad tax base. Comparisons with countries which do operate as welfare states, help to highlight the point further. For example, Norway with a population of 5 million, GNP per capita of US $ 51,600 and 26% of the budget allocated for social services can enable such coverage. Clearly, we are working around very different numbers and population denominators.
The other option is to bridge existing gaps through the development of an overarching vision, policy and operational strategy for social service delivery – one that builds on the efforts underway, bridges existing gaps based on an objective assessment of weaknesses and opportunities with clarity in what needs to be delivered and how. In the envisaged and hoped move towards creating this framework, a number of steps need to be undertaken at conceptual and operational levels. Firstly, on the normative side, the range of these services and their coverage will have to be defined; the choices concerning those services, and most importantly, the means of their provision and the mechanisms of their financing, both over the short and long term will also have to be outlined, ideally through appropriate legislation. This should be done across the range of the traditional definition of social services such a income, food, housing, unemployment benefits, health and education, etc., on the one hand; on the other, across services to the marginalized segments of the population where the commercial sector has a disincentive to provide services as in the case, for example, of rural electrification. And therefore, while decisively pushing the balance in the economy in the direction of private rather than public ownership it must be ensured that the government still has the leverage to play a redistributive role through means other than regulation.
Secondly, the state will have to signal a fundamental policy about the means of delivery of the welfare services. Although we speak of the state as providing services, it is both possible and common for the state to fund services rather than directly take on responsibility for delivery. The Government of Pakistan has traditionally being playing the role, both, of a financier and provider of social services. It must be recognized here that the most important role of the state lies in raising revenues to pay for welfare; however when it comes to the provision of services the system can be organized for welfare provision to harness the capacity of other partners, which can go beyond the institutions of the state completely. Being a financier of welfare and only partly responsible for delivery of services has important consequences for the way a welfare policy is made and will mean that the government will have to interface with the wider range of organizations in the delivery of care.
The need to restructure the means of service delivery has been reiterated by the recognition, especially by the provincial governments in Pakistan over the last five years to deliver services (traditionally in their domain) in an alternative fashion. This is evidenced, for example, by the several ‘pilot’ projects of restructuring the management of Basic Heath Units especially in Punjab as was the case in Rahim Yar Khan, which later shaped into the President’s Primary Health Care initiative. However this program is also a classical example to highlight that the state cannot abdicate its responsibility in case it opts to deliver services through means other than its own. In such arrangements, the objective must be to ensure provision of quality services, garner community oversight and ensure that public finances are used predominantly to achieve the equity objective. It is important to recognize that the objective is not merely to reconfigure management and it is hoped that the RYK upscaling initiatives would factor this into planning.
Another example to highlight this point is the often mistaken case of hospital autonomy.
Hospitals are publicly owned institutions; however public health authorities can contract with providers to supply health care on agreed terms and bring efficiency in management. However this does not mean privatization or turning them solely into profitable enterprises, given that if left to the market, curative care being cost intensive would be excludable for the poor. Therefore in an autonomous hospital, though controls are given to the local administration and the means of service delivery altered, the state must continue to play a redistributive role as referred to earlier by citing the example of RYK. Here it must be recognized that not only markets remain the major channel and option to provide services in exchange for payments, but another tier of government can also be the alternative means of service delivery; for example many services are delivered by local governments after the passage of the Local Government Ordinance 2000. In any case, and in many alternative means, the federal or the provincial government may remain a deliverer to some extent given that teachers and doctors can be paid out of the public purse; in these settings, there is a need to maximize efficiency within the public sector, reduce administration costs, and strengthen the incentives-accountability-performance nexus.
Thirdly, assuming that a decision has been made to alter the mode of delivery, a number of legal, policy and regulatory considerations merit an institutional response to streamline operations at the public-private interface. Autonomous institutional arrangements with appropriate regulatory capacity need to be established for ensuring quality in provision and up scaling of services; precedence has already been set for this approach through the recent creation of several regulatory authorities. Through these, public authorities should be able to contract providers on agreed terms through a competitive process and outline the range of welfare services, the mechanisms of their payments in addition to the modes of the delivery and the beneficiaries of these services. The recent creation of the Infrastructure Project Development Facility is a positive step in this direction; principally geared to infrastructure development, the institution has recently kicked off with a focus on social sector as was evidenced by its thematic representation on IPDFs opening agenda. Delivery of social services in a public private framework will have institutional handling arrangements of the kind which this institution will hopefully develop capacity and linkages for.
In the fourth place, it must be recognized that the introduction of the market mechanism to the delivery services, even if funded by the government, may in cases introduce costs and therefore access issues for the poor; and it is here specifically that social protection arrangements assume importance. Social protection is generally regarded as a mechanism to address poverty and vulnerability by providing protection against uninsured hazards such as illness, unemployment and disasters which push vulnerable households into poverty and the poor into persistent poverty. If equity funds are made part of social protection measures they enable exemption at the point of service and therefore mitigate the risk of exclusion based on access. Pakistan is fortunate to have developed a Social Protection Strategy; the short term recommendations of this Strategy are to “extend existing cash transfer programmes to reach the poorest ten percent of households, and to introduce conditional cash transfer programs to achieve specific objectives”; the latter can be used as part of waiver and exemption mechanisms to obviate point of service delivery charges as in the case of health services where user charges are introduced. This Strategy needs to be implemented with a strong political will. Over the long term, an integrated social protection system based on social insurance and covering the entire population should be the goal; however it does not seem plausible that this goal will be achieved for reasons that are outlined in the following point – most critical to this entire debate about, who actually pays for services.
Within this context, it is generally assumed that there would be a reliance on general taxation to provide the lion’s share for welfare; however, the other way of doing this would be to fund services out of insurance contributions. Here it is important to recognize that the latter has limited value in our context for reasons that must be understood: insurance contributions are usually levied on workers and employees and in a country where 40% of the workforce works in the agricultural and informal sectors as in Pakistan, there would be no structured mechanisms to ensure contributions. Therefore, if pooling is pursued as a long term financing objective, it can only be done so with the understanding that this will be done through state contributions in what could then be called a social equity fund. Would any government be ready to bear the cost of per-capita cost expenditures of the kind necessary to provide cover on these lines to a population of 160 million? Clearly not. However on the other hand, Pakistan is a country with a huge potential to tap into philanthropy as a sources of financing services whereas on the other hand, community cohesion makes it possible to envisage community contributions as a source of possible pooling for services. Interestingly institutional arrangements relevant to both the cases exist and can be used as an entry point; Pakistan Institute for Philanthropy in the case of the former and community linkages, both within the devolution initiative as well as the community networks of organizations such as the Trust for Voluntary Organization and the rural support programs, in case of the latter. The potential within these can be harnessed in building a larger resource base for financing social services.
To summarize therefore, there are clearly things that cannot be achieved as for example aspirations to become a welfare state. Let us accept that and move on. Let pragmatism drive our pursuits and expectations of the range and nature of social services, which the state can deliver in Pakistan. Let us also leverage on strengths that we have and factor them into planning. As already stated, we are not going to be starting de novo in creating a social policy fabric; the individual initiatives, institutions, mechanisms and policies exist, but they need to be woven together, concretized, given a vision and reinvigorated so as to ensure clarity in definitional aspects and the range, choices and means of provision. Existing state institutions such as the Bait-ul-Mal, and the ministries of Social Welfare, Labor, Housing, Health and Education; quasi-state owned institutions such as Pakistan Institute for Philanthropy, Infrastructure Project Development Facility, Trust for Voluntary Organization, microfinance banks and rural support programs, and the envisaged regulatory authority will continue to have a major role in this approach; but their roles, responsibilities and prerogatives will have to be clearly stated and mandated. In addition, the systems levels issues which have been responsible for their failure to achieve stipulated targets must be the target of reform as well. Essentially this approach needs to go beyond a social policy reform to also encompass reforms in areas which reconfigure the governance of the delivery of services as for example, in the case of the efforts underway as part of the National Commission of Government Reform and other civil services and government restructuring efforts; these must pay careful attention to governance and regulatory roles relevant to the social sector.
Policies are, in part, the product of conscious human design and they can also be changed and reformed in order to ensure that they achieve stipulated goals more effectively.
What Pakistan needs at this point is the right capacity at the policy making level with the hope that these will be able to set certain institutional processes in the social sector on the path to sustained recovery. However, we need to be pragmatic in our approach to what can and what cannot be delivered. The utopian vision of aspirations to deliver social services on the welfare model, embodied in manifestos of most political parties and some national documents need to be revisited and rationalized. It is critical to strengthen institutional capacity both within the political system and establishment to deliver on a vision that is feasible to implement and holds the promise of impacting social sector outcomes on a sustainable basis.
The author is the founder president of Heartfile and Pakistan’s Health Policy Thinktank. sania@heartfile.org
The WHO Director General election finale.
Nishtar S. The WHO Director General election finale. Lancet 2007;369(9557):185
A new paradigm for regulating drugs and pharmaceuticals
Published in The News International on January 07, 2007:
Policy issues relating to drugs and pharmaceuticals have increasingly been in the spotlight in 2006; the impetus to this came from the saga of the sale of spurious drugs and the consequent suo moto action by the Supreme Court. Subsequently, a high level committee meeting on October the 2nd, 2006 decided to create a Drug Regulatory Authority (DRA); this positive regulatory change, which has the ‘potential’ to revolutionarize the regulation of pharmaceuticals in Pakistan was therefore very well timed. However this also generates the expectation that the regulatory authority will deliver on its ultimate outcome objective of making quality, efficacious and safe drugs affordable and accessible. Here it must be recognized that the creation of the DRA is an output of a process; in order for this output to impact outcomes a range of issues will have to be understood and addressed. What are these? How do they interplay? And where are their handles? is important to get a sense of, so that a number of caveats can be brought to attention, right at inception.
The first consideration relates to the structure of the DRA, which has been created as a statutory and autonomous regulatory agency; it is here that the real issue lies. How ‘autonomous’ is ‘autonomous’? How ‘representative’ is the ‘governance of autonomous’? What are the ‘prerogatives’ of ‘autonomous governance’? Where are the accountabilities? What kind of ‘controls’ would state institutions have on this regulatory agency? Who will ensure ‘transparency’ and according to what ‘criteria’? These are important considerations which merit careful attention. Then again, even if the right ingredients at a governance and representation level are ensured, the DRA ultimately has to operate through the existing implementation arm, which is where the existing field force of inspectors, quality assurance teams and many inefficiencies and procedural malpractices factor-in. In order to mitigate these structural issues, a number of considerations will merit careful attention at the outset. On the one hand, the Drug Regulatory Authority will have to be appropriately mandated in a role beyond being a clearing house and its governance and management arrangements will have to be made meticulously transparent with broad-based representation so as to obviate commandeering by vested interest groups. On the other hand, the DRA will also have to be appropriately funded so that it can hire staff with appropriate capacity and/or incentivize existing staff structures and create an efficient incentives-performance-accountability nexus.
The second issue in relation to the DRA relates to the gaps in the norms and standards against which it would regulate. The DRA has been created on the premise that it would be made responsible for regulatory aspects of drugs and pharmaceuticals and monitoring of the implementation of the Drug Act of 1976 and the National Drug Policy of 1997. And in this context, it makes sense to see if policy and legislation needs updating in the first place given that they are thirty and ten and years old, respectively.
The Drug Act of 1976 is, by and large, perceived to be a sound piece of legislation. Most of the weaknesses identified in the Act are contemporaneous such as those with reference to liberalization of trade under WTO and the recent information technology boom, which has created a new era for cross border marketing. However, there are other gaps in the Act as well particularly with reference to issues of quality assurance, phamacovigilance, data exclusivity and lack in clarity on the issue of drug pricing, which will need to be bridged in view of the potential impact of these on the scope of work of the DRA. The present Government has initiated steps to bridge another important gap in the law which relates to its lack of attention to traditional medicine; and it would be important to get that bill moved quickly so that traditional medicines can be brought under the scope of the new regulatory parameters. With reference to the National Drug Policy of 1997, there is a need to hone the ‘operational’ focus of the present policy with the understanding that the focus of a ‘medicines policy’ should be to ensure the sustainable supply of quality, efficacious and safe drug, making certain that they are accessible and affordable for consumers and ensuring their rational use in health systems. On this premise it is important to distinguish between a ‘medicines policy’ and ‘pharmaceuticals policy’; the latter is linked to the medicines policy but focuses essentially on matters relating to trade, investment and Intellectual Property Rights. Cleary, state mandated agencies on health have to prioritize the medicines policy piece; in this context, it would be critical to outline the extent to which the DRA is mandated with a ‘pharmaceuticals policy’ implementation role vis-à-vis the Ministry of Health and the level of coordination it warrants with other sectors.
In the third place, in addition to the aforementioned important structural and normative aspects, a priority agenda for the initial scope of work for the DRA will have to be developed through consensus. The agenda should focus on product and quality regulation, price regulation and IPR and patent regulation.
With reference to product and quality regulation, the scope of work of the DRA can include approval and registration of drugs, granting of manufacturing and marketing licenses, regulation to deal with spurious drugs manufacture, ensuring mandatory GMP compliance, overseeing the conduct of clinical trials and ensuring the incorporation of Good Clinical Practices (GCP) protocols to stress on safety aspects of the patients and strict accordance to ethics. The mandate of the DRA vis-à-vis the role that the Ministry of Health will play in these areas will have to be delineated.
With reference to drug registration, there is a need to redefine the scope of registration in view of the understanding that many civil heath products, traditional medicines, medical devices and in vitro diagnostics are outside of its ambit. With reference to quality, the main focus of the DRA should be on strengthening and ensuring compliance with the stipulations of the quality assurance mechanism established under the Drug Act of 1976. A number of approaches can be pursued in line with this; these include making it statutorily binding for manufacturers to have independent quality control and pharmaco-vigilance units, mandating pre-marketing trials and post-marketing surveillance and introducing measures which can increase quality orientated competition among manufacturers.
The DRA should also enforce stricter regulatory measures to check the mushrooming of spurious drugs; these can include norms and standards for manufacturers and importers on sales through appropriate channels; regulation relating to the resale of local/imported and second hand machinery and regulatory stipulations relating to raw material sale and purchase in the market. The DRA will also have to develop its capacity to enforce stricter and transparent regulation to curb a number of illegal practices which contribute to the availability of spurious drugs in the market; these include possession of illegal and fake licenses to sell, duplicate documents, absence of warranty of purchase of all products, gaps in the sale purchase record of all products, inadequate storage practices at outlets and the absence of unqualified personnel at outlets. The DRA will have to develop its institutional capacity preferentially around this core agenda. The DRA should also create windows for the direct involvement of consumers in this arena on the premise that transparency and creation of avenues for consumer interventions can help regulate this sector in an efficient manner and allow broadening of regulation. This should enable the common consumer to launch and follow up complaints against poor quality of medicines. The potential within civil society consumer protection agencies should be harnessed for this purpose.
On the issue of availability, on the one hand the DRA will have to work with the Ministry of Health on the National Essential Drug List (NEDL), which needs to be promoted given that it holds potential for ensuring the availability of high quality low-cost drugs in the public sector and in view of the understanding that it can be used as a tool for rationalizing pharmaceutical expenditure. However the priority agenda in this category would be to redefine the NEDL in order to scale down the number of drugs and eliminate outliers in terms of usage; another priority could be to study the price handles or factors that contribute or have the potential to increase or decrease cost along the supply chain and with a view to curtailing costs in procurement.
Also relevant to the issue of availability, is a set of complex factors, which leads to shortages of many drugs in the market; and it is here that DRA can play an effective role in mitigating/obviating shortages through a number of pragmatic measures. These can include adequate raw material quotas; support for legitimate manufacturing bottlenecks; adjustment of prices of drugs habitually short in the market so as to deter smuggling-out of those drugs; breaking manufacturing monopolies for drugs habitually short in the market; making it mandatory for medicines on the NEDL to be registered by more than one company and statutorily binding regulators to the terms and conditions of registration which also includes assurance of regular supply.
The DRA must also have a role as a priority in strengthening local regulations in line with the international code of marketing practises and ensuring compliance with these practises. Violation of this code such as those evidenced by hospitality-based incentive intense marketing practises, which adversely affect medical practise and treatment decisions of physicians; heavy and inappropriate discounts to retailers which are meant to push products and other unethical practises in order to enhance market share are well established. These will be a daunting challenge for the nascent DRA; notwithstanding, these are issues that must be the target of concerted long term focus.
The other important area for regulation is the area of pricing. The DRA needs to work closely with the Ministry of Health (which has the policy making prerogative) to develop a position on drug pricing; this should essentially be with the understanding that the objective should be to focus on making low priced, quality, efficacious drugs available in the market. However at the same time some incentives will have to be given to the commercial sector for quality improvements and for bringing the benefits of new and better treatment options. The feasibility of instituting policy measures to make low-price drugs available through other mechanisms such as differential pricing also need to be explored. The commercial sector advocates for the phased deregulation of a certain set of products and actives, price adjustments according to prices in countries with similar per capita incomes and voluntary price reductions while allowing subsequent increases up to the original price level. The feasibility of such policy interventions should be carefully explored through appropriate studies drawing lessons from the experience of deregulating price controls in 1993.
The third area of regulation relates to IPR and patent regulation. The scope of work of the DRA needs to play close attention to the implications of liberalization of international trade under World Trade Organization (WTO) agreements on access and affordability to drugs and should additionally, make proactive efforts to take advantage, as appropriate, of certain prerogatives that countries have, to override certain provisions of WTO in the interest of making drugs accessible. Pakistan is a signatory to the Agreement on TRIPS and has promulgated the Patents Ordinance 2000 to comply with its requirements. The DRA should begin by initiating research and studying and analyzing the potential impact objectively and develop a baseline position on the Pakistan-specific public health impacts of TRIPS. Under TRIPS the duration of patent protection has been increased from 16 to 21 years and it is perceived that strong patent protection could mean higher prices of drugs; however given that only 5% of the 1.2 billion pharma market is under patent and given that price determination is in the hands of regulatory agencies in Pakistan the ‘actual potential impact’ of this on drug prices needs to be determined. The extent to which this narrows the opportunity for local manufacturers who compete for market share of generics that are already in their maturity phase also needs to be assessed. In any case, the research and development base of the local pharmaceutical industry needs to be supported in the post WTO scenario given the commitments embodied in the law. This can be part of a much wider drive to increase investments in pharmaceutical R&D in order to make the pharmaceutical sector more knowledge driven in a globally competitive environment; this approach is also in line with stated policy objective to increase pharmaceutical exports. The Ministry of Health has been collecting a Central Research Fund from licensed manufacturers at the rate of 1% of the gross profits over several years under Section 12 of the Drug Act 1976. Recently, there have been attempts to channel these funds for research activities. This is a sizeable fund, and the feasibility of using it for the stated purpose needs to be explored. Collaborative linkages should be established with agencies such as the Pakistan Pharmaceutical Manufacturers Association (PPMA), Pharma Bureau and the Pakistan Association of Pharmaceutical Physicians (PAPP) for this purpose. The potential within regional collaborative initiatives such as SAARC to enhance funding capacity in this area also needs to be explored.
The scope and scale of the afore-stated regulatory roles highlight the daunting uphill task that the DRA is up against. To deliver on an agenda as broad as this, the DRA will have to define a clear agenda, steadily develop its capacity and develop transparent implementing arrangements. However, there is much that is outside to the scope of this institutional arrangement which can influence its capacity to deliver in the stipulated role. Considerations relating to institutional structure and issues inherent to the norms and standards it is supposed to regulate against have already been alluded to. State agencies which will mandate the DRA in its role must focus their attention to these broader considerations and if they fail to do so, the DRA will just be another tier in the present arrangement of the administrative drug hierarchy.
The author is the founder and president of Heartfile – Pakistan’s Health Policy Think tank. E mail: sania@heartfile.org
Dengue and its likes – long term context
Published in The News International on November 05, 2006:
The explosive outbreak of Dengue raises several important policy questions for long term public health planning in Paksitan.
Dengue is making headlines with widespread public attention and political response.
True that Dengue and its potentially lethal complication, Dengue Hemorrhagic fever should be a national public health concern – as they are. By way of contextualizing however, here is a disease that does not spread from person to person and therefore does not require patient isolation and barrier nursing and fortunately its vector (the mosquito) will not be able to survive and breed in the forthcoming winter season. On the other hand many other equally serious infectious diseases (such as Multiple Drug Resistant Tuberculosis) often go largely unnoticed by the general public and decision makers as they do not produce explosive epidemics.
This notwithstanding, the recent mayhem that Dengue has caused and the attention that it has generated, should provide an opportunity to put systems in place to address such epidemics in the future. The Dengue outbreak and the turmoil created earlier by the expectation that SARS and Avian Flu would cross Pakistan’s territorial borders, flag some important policy considerations for long term institutional planning in the health sector.
These broad policy issues are being addressed herewith collectively because all these diseases – despite their etiological differences – fall within the category of emerging and reemerging infections, for which a unified strategy can be adopted nationally. Under the rubric are diseases not previously known, diseases which appear in a new location or in a new epidemic or epidemiological pattern or outbreak of diseases previously under good control. All of these pose a number of challenges; ‘reemerging’ infections such as Dengue need to be grappled with in the absence of vaccines whereas on the other hand, control and prevention strategies for newly emerging infections (such as SARS and Avian flu) suffer several limitations because researchers do not have the opportunity to formulate treatment modalities, vaccines and vector control strategies.
Pakistan has a number of programs aimed at controlling existing infectious diseases; these include the national programmes of HIV/AIDS, Malaria, Tuberculosis and Hepatitis and the National Expanded Programme of Immunization. However the unexpected emergence of new infectious diseases and the persistent threat of reemerging infections, have made it clear that efforts to control existing diseases, need to be accompanied by improved capacity for ‘early detection’ and ‘rapid response’ to newly emergent or re-emergent infections.
Configuring a program on these lines is not straightforward by any means; epidemics are unpredictable in time and place; surveillance efforts are difficult to maintain; sustaining readiness for infections is costly and developing and maintaining vector and rodent control programs are difficult. But this is not a justification not to act since the human and economic costs of these epidemics can be enormous. The influenza pandemic, hundreds of years ago killed millions of people; and even in this day and age of technological advancement, one of the envisaged SARS outcome scenarios predicted the same for the planet; the fact that it was fortunately otherwise, had little to do with manmade maneuvers! In terms of economic costs, the memory of the economic fall out in the Far East subsequent to Avian influenza and SARS should bear testimony to the devastation that such diseases can bring in their wake.
The case for enhancing our capacity to address this public health issue on a sustainable basis is, therefore, compelling. The question is ‘how’. It is within this context that three considerations merit careful attention.
First, there is a need to strengthen and consolidate the existing institutional arrangements and clearly define roles and responsibilities. Currently there is fragmentation in this aspect; policy making is the prerogative of the Federal Ministry of Health but also, in this case, the provincial departments of health given that health is constitutionally, a provincial subject. Diagnostic and technical human resource capabilities are supposed to exist within the Epidemic Investigation Cell, Public Health Laboratories Division of the National Institute of Health, which is in the Federal domain. Here gaps at the resource and capacity level exist and ambiguities about line reporting (provincial-federal vis-à-vis district-federal) have been noticed in the wake of the Dengue outbreak. Information collection and analysis functions exist at various levels; within the realm of provincial/district control, the District Health Officers (DHOs) are responsible for locally collating and analyzing information, but there are serious gaps at the District level in this respect. This information in turn relays to the central Health Management and Information System (HMIS), which is in under the MoH for central analysis and action. However, despite the existence of an elaborate and potentially brilliant infrastructure to collect information, simple easy to bridge gaps still abound. For example, there is currently more than a three month delay before information reaches from the districts to the central HMIS level which is where the analytical capability exists. This gap can be bridged cost-effectively through the appropriate use of technology. It must be appreciated that addressing these challenges at the resource, capacity, line responsibility and reporting levels are central to developing a response capability to emerging and reemerging infections.
The most suitable way of approaching this issue would be to create dedicated institutional responsibility for incident management as a public health program priority. Then there is a question of whether this should operate as a silo mechanism for emerging and re-emerging infections or should this be one that is configured to ’emergency response’ within a broader context. The latter was underscored during and in the aftermath of the October 8, 2005 earthquake as an important consideration. Public health issues after the floods almost each year would also benefit from such an entity. More recently concerns about the intentional release of infectious agents, in a deliberate attempt to frighten, harm or kill should give additional impetus to this effort. Within this context, several acronyms for an institutional entity have been in circulation within the Ministry of Health, the Earthquake Rehabilitation Authority and UNDAC. These should be reconfigured as a Health Incident Management System in Pakistan – a system which incorporates disaster planning within its realm with a focus on preparedness, response, and recovery. Such an institutional entity should foster collective responsibility to complex and unique emergencies – natural or manmade.
Such an agency would have unique normative tasks even out of the ‘implementation’ mode. For example, it can develop protocols for different phases of operations in envisaged disasters and procedures for seeking assistance, locally and internationally. It can also develop mechanisms for ensuring pharmaceutical supply flows and identify potential sources in addition to mapping health sector infrastructure and human resource. The agency can also plan for hazardous waste disposal, inventorize public health demands, develop plans for the provision of needed medical equipment and medical supplies and identify potential sources. The latter can obviate shortages of the kind currently being experienced by DHOs in the field with respect to anti-mosquito sprays needed to contain the Dengue outbreak. Moreover the agency can also ensure regular capacity building of Communicable Disease Control Officers and Sanitary Patrol Officers on an ongoing basis.
Secondly, at a more technical level and relevant to the emergence and reemergence of infectious diseases per se, is the need to strengthen health information systems or more specifically, infectious disease surveillance mechanisms so as to gather evidence needed for an effective response. A lag at this level results in delayed response and increased opportunity for epidemic spread. Effective surveillance is also particularly important in Pakistan because illnesses with similar initial manifestations (malaria, influenza, typhoid fever, hepatitis) are common in the country.
Infectious disease surveillance is largely based on acute epidemic reporting from facility sources. Several vertical infectious disease surveillance systems exist in Pakistan as part of the respective programmes on Polio, Tuberculosis, Malaria, HIV/AIDS. These involve acute case detection and reporting from several sources including HMIS. The AFP/polio surveillance system in particular taps all possible sources for information through active surveillance methods and is recognized as being effective. However, this initiative is part of WHO’s global drive to eradicate polio and has received significant support from it. Other pockets of good practice also exist in various aspects of surveillance. However, by and large, systems have minimal coordination between vertical programmes and they usually do not tap into all sectors, thereby reflecting incompleteness. At the district level, there is limited capacity to analyze and interpret data and utilize it for action, as already mentioned. In addition, these systems have limited capacity to confirm clinically diagnosed cases of reportable diseases because a functional laboratory system does not exist outside of urban areas. This is compounded by gaps in legal requirements to report notifiable diseases. On the other hand, HMIS, which serves as the State’s mechanism of collecting data suffers from several limitations including resource constraints; HMIS does not capture data from several government hospitals and none of the private sector facilities.
In view of these considerations, a number of gaps need to be bridged. Existing piecemeal epidemic infectious disease surveillance activities within individual programs should be strengthened and integrated into a comprehensive public health surveillance system consisting of peripheral data collection arms linked to a central system; this would mean supporting HMIS, broadening its base and enhancing data connectivity through the appropriate use of technology, which can bridge the unacceptable time lags in data transfer. Management information systems in hospitals and private sector should be developed/standardized and data flows to HMIS established.
In addition surveillance efforts should be backed by a legal system that mandates the notification of priority diseases and regulates laboratory practice; within this context, a functional laboratory system for infectious disease surveillance should be supported to the extent that a credible cost-effective analysis suggests. Capacity is key to surveillance efforts as ultimately the purpose is to utilize information for decision making; this is all the more relevant in the post-devolution scenario, where health related decision making is a district prerogative. The recently launched Field Epidemiology and Laboratory Training Program is an important step in the establishment of a surveillance capacity in the country and should be leveraged for building capacity at various levels.
Thirdly, and more broadly again, incident management – as other contemporary considerations in health – reiterate the need for strengthening health systems rather than piecemeal solutions. Indeed many of the measures necessary to address the current challenge are embedded in systems-level solutions. These depend on how the system is governed at various levels; on how clear the federal-provincial-district roles and responsibilities are in the health sector; on how effective the state is in harnessing the role of the private sector; on the effectiveness and transparency of administration and procurements and how effective they are in plugging pilferage and leakages from the system. Moreover, it depends on the capacity of the health care providers, the health service delivery fabric of the State and its capacity to regulate the delivery of services by the private sector. This is a long winded way of saying that new institutions can only be effective in well oiled systems; this once again calls for the need to think strategically about a health reform in the country without which creating regulatory or legal or institutional interventions will remain just acronyms.
Some of these broader policy issues relating to restructuring the mode of health service delivery in the country are fundamental to addressing public health threats, which emerge from time to time. There is every reason to believe that a number of factors will be shaping the public health landscape very differently to the manner in which it is currently configured presently over the next decade or so. Microbial adaptation, travel, environmental changes such as global warming and changing ecosystems have implications for spread of disease and its control; humanitarian crises, conflict and intent-to-harm related public health challenges are a contemporary reality and there is not guarantee that seismic activity of the kind witnessed last year will not continue.
Within this context and from a policy perspective, it is important to rely on institutional preparedness rather than ad hoc responses. There can be no argument against capacity for Incidence Management, but what is more important is to also focus on systems through which they will be delivered.
The author is the founder and President of Heartfile and Pakistan’s Health Policy Thinktank. E mail sania@heartfile.org
Opening the insurance market – the health perspective
Published in The News International on October 01, 2006:
The Economic Coordination Committee of the Cabinet on Wednesday the 27th decided to allow foreign companies to invest in the insurance business in Pakistan on the premise that this would help attract Foreign Direct Investment (FDI). There can be no two opinions about this being a right assumption if the necessary regulatory environment is secured. But then the other important factor critical to the success of this approach has to do with the issue of demand, which depends on the real disposable income of the prospective policy holder and the individual’s perceptions about the need for financial security. In Pakistan’s case where 67.% of the population lives in the rural areas and given the low per capita income – the recent increases notwithstanding – the question of demand is all the more relevant and one that needs to be factored into expectations.
Then again to put things in context, FDI assume importance as it can impact macroeconomic indicators and again there is no arguing about the importance of the latter, but what is also of significance in this case in point is that here is also a case of a regulatory intervention, which has a bearing on social sector outcomes, particularly with reference to the role that can be played by insurance companies in health insurance. And therefore, in tandem with the government’s policy of augmenting FDIs, attention must also be paid to other regulatory and overarching structural changes which can, on the one hand, assist in achieving a range of social sector outcomes whereas on the other, make it viable for insurance companies to invest in Pakistan. Clearly with reference to the social sector opening up the market to foreign insurance companies cannot be seen as an end in itself.
The case of health insurance, which is classed in the non-life insurance category will be used to illustrate this point. However here a distinction should be made between Social Health Insurance and Private Health Insurance in order to clarify that Private Health Insurance has a capacity to mobilize funds from people who can play and wish to be ensued; however it cannot provide financing for the poor. Health insurance arrangements for the poor come within the ambit of Social Health Insurance, which though more important is not the subject of discussion in this article.
In the first place, why do we actually need to think in terms of health insurance? The answer to this is embedded in the health financing landscape of Pakistan. The total health expenditure for Pakistan is estimated at US $ 16 per capita; of this US $ 6.3 is contributed by the public sector largely through general revenues and the rest by the private sector through out-of-pocket payments. When viewed against global recommendations which recommend public sector health expenditure to be at least US $ 34 in order to deliver essential health interventions to meet MDGs by 2015, a huge gap is clearly evident. And it is here that the role of alternative health financing options becomes important.
Private health insurance certainly has a place – albeit small – in bridging the mismatch between the current health financing strategies and the nation’s health sector financing goals.
The second question: who benefits when private insurance companies operate in the health sector and why? Here it must be understood that private insurance industry largely act as a source of financing health in individual or group settings and with reference the latter, through employers, in particular.
The third question: Where are the impediments then, which need to be addressed?
This is a particularly relevant question given that after the passage of the Insurance Ordinance 2000 certain areas in non-life insurance such as motor insurance did quite well whereas the social sector was unable to reap the benefits of policy change. There are several reasons for latter. Firstly, there is lack of demand for health insurance owing to high cost of service. Secondly, the major bulk of Pakistan’s workforce is in the informally employed sector and the absence of financial guarantees to the insurer results in limited incentives for health insurance companies to cover the informal sector.
Thirdly, there are issues at the end of health providers with the market being fragmented and professional practices not being accredited. Health care providers also do not ‘buy into’ health insurance given that this has tax-related implications. These considerations underscore the need for building appropriate incentives at several levels.
The fourth question: what are these incentives, where are the handles and what are the solutions? The solutions lie in carefully balancing incentives for the three key players in this arrangement – Insurance companies, Providers and Employers – through appropriate policy interventions.
As far as the first stakeholder is concerned – Insurance companies, it is important to attract companies that can draw a large number of people in a pool; however this is dependent on the capacity of the insurance company and only those with large institutional bases, investment capacities, and a rich domain experience are able to create such incentives. An analogy can be made with the growth of mobile phone industry in the developing countries and indeed in Pakistan where companies have leveraged on their domain experience in the developed world. Appropriate incentives can be given through the FDI policy of the Government of Pakistan and the regulatory environment which the Government provides to regulate financial practices of health insurance industry. For example, insurance regulations can be eased and tax rebates and a certain level of financial protection can be given to attract appropriate insurance companies. However these conducive measures should be balanced with careful regulation of the financial practices of health insurance industry, patient centered standards and norms; transaction standards, health service providers’ privacy rules, procedures for claims processing and modes of payment, accountability procedures and other administrative back office procedures – clearly pointing to significant institutional capacity which will be required at Pakistan’s end to regulate this market. Then there would be concerns that easing of insurance regulations and opening up of a new sector is at the cost of the local industry’s interest. However there may be ways of obviating this concern through measures such as cap on equity etc. Useful lessons can be learned from other countries that have developed similar policies.
The second stakeholder is the employer. This is essentially the single largest factor which determines the growth of the insurance industry within the country. A review of the growth of private insurance companies in the developing countries shows that growth is generally paralleled with economic growth in general and growth of the formally employed sector, in particular. In some developing countries, rise in business process outsourcing created opportunities for global employment practices thereby creating an environment where employers subscribed to health benefits. For a start, the Government of Pakistan can offer tax rebates and other incentives to employers for introducing/mainstreaming the health insurance approach to financing health in institutional settings.
The third stakeholder is the provider, to whom appropriate incentives should also be given to subscribe to health insurance. One way of doing this would be through underwriting a large number of people in a pool – an opportunity providers would wish to avail and may compete for, hence brining down costs. Only insurance companies with the right capacity will be able to do that, as already discussed. On the supply side, the provider market should be consolidated. As opposed to preventive healthcare where State mandated healthcare agencies play a pre-dominant role, a number of actors within the healthcare system other than the State play a role in providing personalized curative healthcare, which is what private insurance industry generally works around.
The sector constitutes a set of diverse group of unregulated health care providers. Clearly the regulatory side of credentialing of doctors, licensing and accreditation of service delivery facilities, continuing medical education, performance assessment, quality assurance mechanisms and the monitoring of errors is an important regulatory imperative in order to institutionalize health insurance. And it is within the framework of these regulatory interventions that appropriate incentives for enhancing the use of insurance as a health financing option can be built. There is evidence that the right policy interventions do work! For example, motor insurance showed growth over the last decade. In many ways, it may not be fair to compare this with health insurance due to the differences in the nature and frequencies of risks involved – people get sick more often than they lose cars to accidents and robberies! Notwithstanding, conducive measures need to be explored for the health sector and the handles on the impediments need to be understood.
Over the last few decades, of the 54 private health insurance companies operating in Pakistan, group health insurance is offered by seven insurance companies and individual health insurance by only one company – Allianz EFU. Clearly we are not a conducive market for private and group health insurance. However, with economic growth and consequently and hopefully, the adoption of global employment practices, it is expected that employers will increasingly subscribe to health benefits. The health sector can only tap the potential within such arrangements if they know where to intervene through normative and regulatory interventions on the health side to capitalize on this specific health financing opportunity. The health sector will, it seems, have an opportunity to ride a wave; but they must know how to do it well.
The author is the Founder President of the NGO Heartfile and Pakistan’s Health Policy Think Tank/Forum. E mail: sania@heartfile.org
Playing Social Protection with a new stack of cards!
Published in The News International on September 30, 2006:
We have a history of starting things denovo in this country. Individually and institutionally, we must scrap past initiatives, create silos, never build on efforts underway and whenever the adage “we have never learnt from the past” is referred to it is often with a negative connotation. Why should the case of social protection be any different? But perhaps in the given context of ‘never having learnt from the past’, social protection is unique since the most substantive example of social protection in the country is neither cited nor quoted or referred to in any of the Government of Pakistan documents nor has it ever been referred to by any of the myriad of outputs on the subject by development agencies, with particular reference to World Bank and Asian Development Bank assessments. Furthermore, the example has also been glaringly absent form the recent Social Protection Strategy of the Government of Pakistan released recently by the Ministry of Social Welfare.
But perhaps a discussion of this should be preceded by an articulation of its relevance – not by way of heightening suspense but by way of contextualizing it!
Social protection is a mechanism which mitigates the impact of adverse effects such as illness, unemployment, old age, environmental hazards which push vulnerable households into poverty and the poor into perpetual poverty. However, social protection is not a singular term and consists of both ‘programme approaches’ as well as ‘policy interventions’ and often a combination of both. These either operate and provide assistance through cash transfers or pool resources for providing insurance. Examples of both exist within the country. The current conditional cash transfer programs include the Guzara Program and the disbursements through Zakaat and Bait-ul-Maal whereas examples of in-kind contributions include the Tawana Pakistan Program, where school children are fed nutritional supplements.
Several examples also exist of the other social protection arrangements which pool resources for insurance functions as opposed to cash and in-kind transfers. Most of these are applicable to employees within the formal sector where mandatory salary deductions at source can enable pooling of resources. Examples include the Employee Social Security Scheme as part of which a certain category of employees make compulsory social security contributions for a specific purpose – prepayment to cover health risk and old age benefits. Presently operational in three provinces, and covering more than 1.2 million employees, all private notified industrial and commercial establishments with more than 10 employees under a certain salary scale have to contribute to this scheme. In addition, the Workers Welfare Fund pools resources for providing benefits for housing, schools and health facilities to the formal sector workers earning less than Rs. 5000/- per month, and the Employees Old Age Benefits provides old age pensions in cash, also to the formal sector employees. The programs mentioned herewith as examples of social protection have their own legal policy and institutional requirements, which notwithstanding their gaps have enabled them to provide cover to more than two million individuals within the country. However, sometimes policies can also act as specific instruments for social protection – for example levying Zakaat on bank balances; providing subsidies on food such as in the case of the wheat subsidy, introducing labor laws that mandate social security contributions and institutionalizing old age pensions, etc.
There is ample justification for mainstreaming social protection within the country, even in the face of the recent poverty estimates which have reportedly declined to 23.9%. Constitutional obligations as articulated in Article 37 and 38 in which the relevant rights of individuals are spelt out, make a strong case for placing social protection high on the national development agenda. Official figures quote that currently 0.5% of the GDP is spent on social protection; however if the State’s contribution to health is added to this, the figures would be higher; albeit still less than what is recommended internationally.
In all fairness successive governments since the inception of the country have been introducing various social protection programs. However a number of challenges and issues in the current social protection mechanism are evident. These, inclusive of insufficient coverage of poor households, low spending and the lack of coordination between agencies and possible duplication have also been referred to in the recently tabled Social Protection Strategy. In addition, it is well known that many social protection interventions bypass the poor. The Government of Pakistan’s Social Protection Strategy states that it will attempt to obviate these issues by envisioning better linkages, clearly defining institutional roles and responsibilities, and strengthening existing mechanisms particularly Bait-ul-Maal. However, the strategy is based on the premise that the most effective way of achieving objectives in the short term is to extend existing cash transfer programs to reach the poor 10% of households. And although a number of recommendations have been made to broaden the ambit of the currently existing social protection arrangements, it appears that the strategy hinges on resources from tax funded general revenues or the Public Sector Development Programme Budgets. The strategy does not substantially factor in community contributions or employee schemes given that the introduction of these, though more sustainable on a long-term basis, would involve broader changes in the country’s institutional and organizational frameworks and introduce some form of compulsion to make voluntary contributions – an approach clearly not in political interest in the present situation.
With this as an ode to a context, the most sustainable social protection mechanism within the country merits description – one from which no one has ever drawn any lessons.
Perhaps also the most novel, in addition to being the most sustainable!
Social protection is traditionally funded through tax based revenues or compulsory contributions deducted at source from the salaries of employees in the formal sector.
Perhaps the most novel, way of financing social protection would be to support it through profits generated by commercial ventures. However, there aren’t many examples of social protection arrangements in the world funded through this approach. Pakistan takes the lead in this area with the example of the Fauji Foundation System, a system which provides the social protection to a population of 9 million individuals in the country on a completely sustainable basis. This example is often not highlighted presumably because of the misperception that this is within the ambit of military operations and that citing financing arrangements of military establishments is taboo; this is wildly incorrect. Fauji Foundation is institutionally independent, has never received support from State funding mechanisms and has been running autonomously for the last 50 years as a commercially viable and profitable but non-profit entity which has an unprecedented use for the profits it generates – these go to providing health, education and other social protection services to 7.4% of the country’s population.
Established as a charitable trust incorporated under the Endowments Act of 1890, Fauji Foundation was created after the Second World War out of the Post-War Services Reconstruction Funds in 1942, which were meant to be used for resettling soldiers in civil life after the war. Of the 98 million collected at the end of the war, what was then West Pakistan inherited 35 million in 1947 and in 1954 a balance of Rs. 18 million was placed under the administrative control of a committee with representatives from the three military establishments. The use of paltry Rs. 18 million can be referred to as the most ingenuous and commercially viable as well as the most socially responsible use of moneys in Pakistan.
With a currently estimated tentative market value assets of Rs. 129 billion, Fauji Group has a commercial and a welfare arm; the former consisting of enterprises, which continue to support the extensive infrastructure of the latter. Starting with Jehlum Textile Mills in 1954, Fauji Foundation currently fully owns a range of industrial projects, fully owned commercial plants and generates income from a range of associated companies employing 11632 people – 60% of the workforce is drawn from the civil sector. The welfare side of the group on the other hand was established in 1959. The current yearly expenditures as estimations for last year, stood above Rs. 2.5 billion of which the major chunk was for health (1.6 billion). The Fauji Foundation system has a unique combination of a commercially viably arm that makes profit – profits are used to sustain its administrative arrangements but the major portion goes to serve the welfare arm of the organization and supports the extensive infrastructure through which welfare services are delivered. These include 102 schools, 66 vocational centers, 11 technical centers, 11 secondary and tertiary care hospitals with a bed capacity of 16001 all over the country and 100 other medical care units which fall under the primary health category and 1 artificial limb center which looks after 8000 patients. These provide services on a totally sustainable basis to 9 million individuals in the country which constitute 7.4% of the total population of Pakistan. It is important to note that on no occasion has Fauji Foundation received any state support in terms of public sector program allocations.
Critics argue that this is a military establishment configured solely for the x-military families. And true the beneficiaries covered under this arrangement in various categories are released, retired and discharged personnel of the forces excluding officers and their dependents, as per certain criteria. But it must be recognized that social protection arrangements have to be configured within a ‘given population’ according to ‘some parameter of qualification’ for inclusion. Within these confines, the creation of a commercial establishment and utilization of its profits to cover the risks of 7% of the Pakistani population is an example, which should not be brushed under the carpet within the ambit of social sector policy within the country.
Fauji Group is perhaps one of the few organizations in the country which is truly living up to its mission “to multiply the resources of Fauji Foundation for maximization of welfare activities for the benefit of its beneficiaries”; issues, challenges, and criticism notwithstanding the State’s social welfare institutional mechanisms have much to learn from this experience. However, key to such arrangements is lean and efficient governance and the factoring-in of appropriate incentives and performance based rewards into sustainable administrative arrangements; this is where the extrapolation of this experience to the State’s business model may be problematic – but perhaps also instructive to targeted policy interventions! This is becoming even more important as we see market mechanisms become the driving force reshaping the way the government does business.
Delivering on social sector services is a State mandate – ubiquitously and unarguably!
But then other than the high income Nordic countries with strong overarching social protection mechanisms and huge investments in the social sector where does the assumption apply? Countries such as of Pakistan may never have enough resources for cash transfers to protect risks in an environment where booming market dynamics, vested interests, institutionalized corruption and profit margins play heavily into the delivery of social services. In any case the latter are being made increasingly difficult in a globalized world where access issues emerge in view of liberalization of services, traditionally in the public domain.
The State will have to find new solutions to mitigate the impact of adverse effects on its vulnerable populations; critical to this approach would be the definition of new norms and standards and redefinition of the role of the State in the provision of social services. The State will have to strengthen its ability to regulate and broaden the base of the civil service reform process to a public sector reform process alive to these realities. In addition, it will also have to create frameworks that both regulate and facilitate the private sector as well as create strong institutional frameworks to offset the risk to the poor and disadvantaged in an environment where social services are being increasingly sold for a cost. Clearly we need new solutions; clearly the State needs to play Social Protection with a new stack of cards. After all, in any game you need new antics as the turf changes!
The author is the Founder President of the NGO Heartfile and Pakistan’s Health Policy Think Tank/Forum. E mail: sania@heartfile.org
Health in Executive Committee of the National Economic Council (ECNEC)
Published in The News International on September 10, 2006:
The configuration of the four health projects presented to August the 23rd’s Executive Committee of the National Economic Council (ECNEC) meeting raise some broader issues that need to be the substrate of contemporaneous conceptual thinking with reference to health and health sector allocations in Pakistan. Agreed that there can be no generalizations with respect to the patterns observed in the presentation of health cases to ECNEC; accepted that ECNEC also sees – and approves – the likes of mega budgeted primary health care and preventive interventions and acknowledged that the four projects presented must have been reflective of provincial and district health needs. The purpose here is not to debate the merit of these but to galvanize a thought process and flag the broader questions of priorities for resource allocations in the health sector, the manner in which these priorities are set and the criteria according to which these priorities are determined. Clarity in addressing these questions is a priority now more than ever given the recent increase in budgetary allocations for health.
Is it a matter of chance that only tertiary care focused curative projects gain access into discussion portfolios at ECNEC or is it that such visible and tangible projects have a higher likelihood of being blessed in planning circles; what bearing does this have with respect to the policy positions of prioritizing prevention as part of national health planning; do provincial governments actually sign up to policy positions stated by the Federal Government given that they regard ‘health as a provincial subject’ and most importantly, where does the ideal balance between the prevention-cure-allocation-distribution pitch in Pakistan’s setting and why are questions that need to be debated.
All of the projects tabled at ECNEC were incidentally from NWFP and all of them were deferred. Three out of the four agenda items on the portfolio related to hospitals, which primarily roll out the curative personalized model of health care. When viewed within the context of the State’s mandate to deliver health (at least its priority services) as public goods, this brings to the forefront the debate over the nature of some curative services as qualifying to be termed as ‘public goods’ given that clinical services are thought of as being highly discretionary. The proponents of prevention argue that prevention services, on the other hand are more homogeneous, less discretionary and more cost efficient. Such resource allocation debates are often seen at DDWP and CDWP meetings within ministries and the Planning Commission respectively and are frequently the subject of dialogue between the government and NGO lobbyists. However sadly in such settings, powerful clinicians which make a strong argument for investments in curative care – often tertiary – and the public health community which lobbies for prevention support are often seen as operating within silos with the common denominator being the desire to cut budgets off each others platter. What is infrequently understood is the level of balance that has to be achieved and the reason why it is imperative to do so both within the context of the ‘public health prevention imperatives’ on the one hand and with reference to the States ‘responsibility to deliver curative services at least to a certain segment of the society’, on the other.
Balance dictates that whereas prevention and health promotion need to be delivered as public goods and prioritized, there is also valid justification to invest in hospitals given that if left to the private market, curative care, being cost intensive and rival in consumption would be excludable for the poor creating serious access issues. The State cannot relinquish its responsibility to cater to the needs of those that require curative care particularly the segment of our population which qualifies to be benefited under Article 38 of the Constitution of the Islamic Republic of Pakistan. This realization should also be instructive for the current restructuring arrangements of the State’s infrastructure in health with particular reference to hospital autonomy and BHUs restructuring. Though these are steps in the right direction, there should be a fundamental difference between privatization which is what cannot be recommended for the State’s health infrastructure and mainstreaming the role of the private sector for improved management, and enhancing efficiency, which is what should be promoted. Within these settings, the State’s funding should be used through appropriate waiver and exemption mechanisms to ensure that the poor are not excluded from care. This understanding must also guide the impending GATS-driven liberalization of services, which have traditionally been in the public domain. As curative services are – and will continue to be – mainstreamed on free market principles as a result of the prevailing market dynamics, the States health sector must ensure that access issues for the poor are minimized and mitigated and within this context, a myriad of options can be explored for alternative health financing arrangements and appropriate regulation framed. Health cannot be left to the free market. The fact of the matter is that the State’s hospitals – notwithstanding their gaps and inefficiencies – are the only sanctuary for the poor, at least a certain percentage.
Within this context therefore, what is underlying connotation within the frequent criticism generated in the health sector relating to the sizable chunk of health allocations, which go to serve hospitals particularly in the provinces? Is the undertone one of cutting the budget for hospitals and diverting them to prevention? Perhaps not.
The connotation should be to enhance allocations for prevention and health promotion to achieve a balance that is desirable rather than divert money from hospitals which do play a role in providing affordable care and physical access to clinical services – though of questionable quality – to the excluded vulnerable and difficult to reach populations, which are and should be the prime targets for government subsidy. And with reference to hospitals such criticism should be constitutively directed to ensure that these ‘allocations’ are ‘utilized effectively’ and are not pilfered. It also must be ensured in particular that the high cost services that hospitals can offer do actually benefit the poor, as opposed to the non poor who are likely to use their political influence to ensure that public spending for these expensive hospitals is maintained – often at the expense of services that could have a real effect on the poor. And lastly perhaps the connotation is also one of strongly voicing the need to integrate prevention into the mandate of clinical services, and move away from the silo operations given that these are inseparable – a suggestion of relevance to the Peshawar Institute of Cardiology for which over 1000 million are likely to be allocated in the next ECNEC meeting.
And now with reference to the fourth project tabled at the ECNEC meeting, there can be no argument to support allocations to build infrastructure to support a medical school that has been running without any physical infrastructure for the last five years! But then extrapolated to the broader context of resource allocation priorities in the area of health related human resources, the current doctor to nurse ratio of 2.7:1 and doctor to paramedic ratio of much lower is instructive given that it is clearly opposed to the conventional global norm which advocate a doctor:nurse ratio of 1:4. These qualitative considerations and the established qualitative and deployment related gaps and absence of a continuing medical education program highlights a clear direction to invest in a specific line of human resource from qualitative, quantitative and deployment-related perspectives. At a broader level this underscores the need for decisions on human resource to be based on providing sustainable public health solutions rather than political expediency.
The discussion on priority setting cannot be complete without a reference to the criteria for priority setting within the public health prevention framework. Here if priorities for resource allocations are based on prevailing disease patterns then it may be worthwhile to note that infectious and non-communicable diseases contribute 38% and 37% of the disease burden respectively – an equal disease burden. This criteria alone calls for major shifts in allocation trends even if the other criterion – the potential for preventability – is not factored into the equation, the addition of which would make the argument much stronger. The need is also reiterated if another criterion is applied based on the manner in which health links in with over-arching social sector directions of the country such as poverty eradication. The current health related poverty reduction strategy mirrors the MDG objectives with a focus on maternal and child health and infectious diseases on the premise that these are more frequently encountered in the poor. That is indeed the case. But we also need to be clear on how poverty eradication can link in with the health agenda in economic terms. And in line with this diseases that affect the economically productive workforce; ailments that undermine the income generating power of a household; diseases that have the potential to perpetuate an acute poverty crisis and contribute to major costs of care and put of pocket payments should also merit a consideration. A recently reported population-based cross-sectional survey, has shown that 37.4% of the households spend an average of Pak Rs. 405 on the treatment of communicable diseases whereas 45.2% of the households spend an average of Pak Rs. 3935 on the treatment of non-communicable diseases over the last one year. These data show that a significantly higher percentage of households spend more on treatment of non-communicable diseases compared with communicable diseases.
All said and done in relation to priorities for allocations ‘within health sector’; but perhaps what is more important to deliberate upon in a very broad sense relates to how health factors into the equation of priorities in a much larger picture where there are other competing interests. That will be left to a viewpoint which merits a much richer discussion – one that space will not permit this time round.
The author is the founder and president of Heartfile and Pakistan’s Health Policy Thinktank. E mail: sania@heartfile.org
Tools for treatment – Scope for using technology in reforming and improving the health sector is immense
Published in The News International on August 27, 2006:
Why does technology get spotlighted in the discourse over health outcomes and the discussion on health sector reform? For the simple reason that health and technology have shared agendas. It is well established that in addition to serving as a sine-qua-non of therapeutics and diagnostics in the medial field, technology can not only reduce health-related costs but also medical errors, which are the fifth leading cause of death in countries such as Pakistan. This realization has lent impetus to the emergence of a number of institutional, individual and group professional efforts, in the country, over the last two decades aimed at mainstreaming technology into public health and health systems. Although these are steps in the right direction these need to be strategized and their objectives honed to ensure that they are in line with meeting priority health objectives.
Within this context, several examples can be quoted of pilots within Pakistan from which evidence can be gathered relevant to the feasibility and cost-effectiveness of up-scaling particularly in the areas of telemedicine, e-solutions in hospital settings, capacity enhancement and learning, collection of data and its management and information dissemination. Telemedicine, in particular, has had several applications as a result of the existence of appropriate network connectivity and tools. For instance in the Holy Family Hospital Rawalpindi, networking capacity, availability of audio-visual conference facilities and necessary work flows have enabled the creation of a telemedicine network, which benefits a remote Tehsil Headquarter hospital. Similarly the Rawalpindi General Hospital’s Department of psychiatry leveraged the same concept for serving the mental health needs of the earthquake victims in the post October 08 scenario with successful results, which have been published. However it must be recognized that the existence of appropriate infrastructure is key to the success of such arrangements, which explains why some telemedicine projects in remote areas such as in the case of the Baltistan Health Foundation intervention in Gilgit is experiencing operational difficulties. This clearly highlights that the availability of telecommunications infrastructure is a prerequisite for telemedicine; given this realization, it can be inferred that it is not feasible to introduce in any setting. Another important issue to address in this context relates to health provider buy-in. The documented successes to date have used doctors in a pilot setting; however for large scale application, the question of what constitutes the right incentives to work in such an arrangement on a sustainable basis is one that needs to be addressed pragmatically.
The second application of technology is in the area of providing e solutions in hospitals. It is well established that one of the tools used in this area – Position Order Entry (CPOE) – can contribute to reducing medical errors whereas the other tool which involves Clinical Decisions with Support Systems (CDSS) can and assist in improving health outcomes. Successful examples of this application also exist in the Pakistani setting. Perhaps the most ambitious and progressive IT-based project undertaken in Pakistan is the end-to-end, fully integrated Health Management System currently under implementation at Aga Khan University Hospital. Using Oracle database and tools, Fauji Foundation hospital’s technology team has developed “Medix” – a cost effective, simple to devise and easy to use customized software application used to manage their health system. A similar exercise has been undertaken by Shaukat Khanum Memorial Hospital whereby the hospital’s internal IS team has developed a software application customized for SKMH, again using Oracle technology. Ziauddin Hospital in Karachi is the first mid-sized hospital in Pakistan to opt for buying vs. building a solution. Not only are these off-the-shelf solutions available in Pakistan, there are System Integration experts in country who can help a hospital deploy and maintain these. Here it should be realized that these are viable options for the private sector given that the investments when measured against the advantages such as cost-control, error-reduction and efficiency enhancement appear nominal. However when public sector finances are taken as a denominator, the value of these approaches in terms of wide scale application and the benefits gained in terms of improving health outcomes vis-à-vis costs incurred are not clear yet. Then again there are issues relating to how technology can be – bought and – introduced into hospitals, which are being made autonomous; this highlights issues relevant to the terms of reference of autonomy and the manner in which they impact unified technology applications, which is what appears to be the most cost-efficient.
The third area where technology can play a major role in health is in the area of health information systems. Pakistan currently has many sources of health information: the Health Management and Information System (HMIS), the management information systems of various public health programs, standalone surveys, mortality projections, population-based surveillance mechanisms and the acute epidemic reporting and surveillance system are all potential sources of health information. This notwithstanding, there are major gaps in information gathering, its collation and reporting and it is here that technology should be leveraged as a priority. For instance in relation to HMIS the speed and access to inter-connectedness can obviate delays in the transmission of data, enhance the quality of data and software applications can improve modeling projections. In addition central data management software can revolutionarize data management and information deliverables which are critical to bridging the data-information-evidence-policy loop. The application of technology for strengthening health information should receive careful attention given the strong case for institutionalizing health information as a priority at a health systems level.
The fourth area of application relates to e-learning. In Pakistan, 70% of the health care delivery is through private sector for which there is no program for Continuing Medical Education/Training (CME). Training activities for the public sector health care providers are sporadic and do not conform to contemporary health care needs. On the other hand, the boom in information technology in the last decade has dramatically improved communication in Pakistan. In particular the recent introduction of Wireless loop technology (CDMA), must be capitalized upon for improving health outcomes given its outreach in remote areas, lower cost, high speed, which allows the transmission of heavy data files and transfer of images and voice files and flexibility to enable local language software to be utilized for purposes of education. Within this context, use of rugged versions of the handheld computers capable of wireless local data collection/information dissemination can revolutionize connectivity with physicians and non-physicians health care providers in the far flung areas – an opportunity, which must be leveraged for physician and patient education.
Lastly, yet another application of technology is in the area of creating a central health data repository and maintaining national health records. This becomes even more important as we move towards social health insurance which will require precise identification of records amongst other things. This may technically be possible in Pakistan given that two out of three requirements to develop a central health data repository are already in place: a central repository of identifiers exists in the shape of NADRA and a central repository of providers exists in the shape of PMDC. However in order to meet the third requirement, Pakistan will have to go towards adopting common data standards such as the internationally recognized HL-7. This raises the policy question relating to the Pakistani Government’s commitment to enforcing consistency in data standards, complying with prescribed international obligations and publishing minimum data standards which can then be called the Pakistani HL-7 standards.
Clearly technology has wide application in health from which it cannot be extricated. However the key question in Pakistan at this point relates to whether we have the evidence of viability and cost effectiveness of these interventions? And it is here that based on the existing experiences, many lessons for generalization can be drawn. However in terms of a way forward at a policy level, it is important for the government to allocate resources for e-preparedness at an institutional level so that viable technology solutions can be arrived at for the health sector.
It is imperative that as the market dynamics continue to bring technology to the forefront and lead to the development of relatively elaborate – by developing country standards – telecommunications infrastructure within the country, the social sector – and health in particular – must benefit from this opportunity. The challenge however for the Government to address is to set thresholds based on equity and ensure through an unbiased regulatory role that the market does not overplay considerations of outcomes – drawing that line is not going to be easy.
The author is the Founder President of the NGO Heartfile and Pakistan’s Health Policy Think Tank/Forum. E mail: sania@heartfile.org
Rahim Yar Khan health initiative – revisited
Published in The News International on August 06, 2006:
Perhaps no other health policy intervention in recent times has been the substrate of a greater controversy compared with restructuring the mode of primary health care service delivery in Rahim Yar Khan (RYK) as part of which the management of Basic Health Units, in twelve districts of the country, was handed over to the Punjab Rural Support Program in Punjab, beginning 2003.
True that an overview of health policy and regulation in Pakistan can highlight many sore spots; the generic drug scheme of 1973, partial deregulation of prices of drugs in 1993, the institutional based private practice fiasco in NWFP in 2002 and the more recent PMDC scuffle are examples of contentious policy issues. However what makes the RYK initiative unique is the length of time for which the controversy prevailed, the utter discord in professional opinion on envisaged merits and demerits, the lack of consensus over how the initiative needs to be contextualized in the overall context of health reforms within the country, lack of full ownership of the State’s health machinery and most importantly, lack of clarity on steps ahead. This article attempts to bring clarity of some of these issues and proposes a way forward.
A few clarifications before that, though, just to emphasize the importance of consensus building and institutional buy-in in strategic planning. It is often said that a strong political will is critical to fostering change. True that political will is a sine qua non of directional change – but perhaps not the only! And the RYK example just helps to reiterate the point. Called the Chief Minister’s program in Punjab and currently on its way to being expanded in all the four Provinces as the President’s initiative, the RYK initiative was backed by strong political support at the highest level and in all fairness, through well-intentioned bold decision-making. However despite that, the initiative has fallen prey to turf battles and implementation challenges only to show that in addition to political will, the consensus of stakeholders, institutional buy-in and directional clarity are, and should be the key ingredient of structuring new initiatives. Within this context, a number of questions, which have emerged since the launching of this program with respect to the institutional, structural, service delivery and public health imperatives are flagged hereunder and a viewpoint articulated on how to address them.
Was there a need to restructure the primary health care system in Pakistan?
The answer to this is an emphatic ‘yes’, albeit with several careful considerations. Primary health care, in layman’s terms, consists of both the public health programs and infrastructure for delivery of basic health services. The former in Pakistan consists of several federally led public health programs with implementation arms in the provinces and the districts whereas the latter consists of 5301 BHUs and 533 RHC – which by infrastructure standards is one of the most elaborate in the developing countries. However, functionally, factors such as staff absenteeism, infrequent availability of essential medicines, poor attitude of staff, inadequate quality of care and other issues such as difficult geographic access have led to an unacceptable level of underutilization and performance. Radical measures to reform the system were therefore not just needed but also timely. However it must be recognized that there were various options for restructuring BHUs which could have been considered. Contracting out management – the model opted for in RYK – is certainly one whereas the other options include transferring management to lower levels of government – either to the District Government (already introduced through the Devolution Initiative) or even to Tehsil Municipal Administration or Union Councils or maximizing efficiency within the existing system by decentralizing and granting greater financial and administrative controls to in charges of the health facilities, EDOs, and/or contracting in skilled managers at market salary to manage the system from within. In hindsight therefore, the RYK initiative should have been cited within an explicit macro policy environment which offered options for restructuring, which respective provinces and districts could choose from based on what seemed locally viable.
What should be the objective of restructuring Basic Health Units?
The ultimate objective of ‘restructuring BHUs’ should not be to ‘restructure management’ but to ‘reconfigure the mode of primary health care delivery’ with the understanding that improving management is a first step towards improving health outcomes within communities. Within this context, the RYK initiative has clearly shown management level success in terms of increased utilization of BHUs as is evidenced by high patient turnover, increased availability of drugs and better financial management; the initiative has also ensured increased field outreach to clients in 12 districts, primed schools to the concept of health promotion and most importantly addressed the issue of staff absenteeism by giving health care providers including women Medical Officers appropriate incentives to serve on station even in the remote areas. The merit of this approach is not under question here. However what is up for debate are two points: one relating to the question of whether the same results are possible if administrative and fiscal control is given to the government’s systems or using other options and the other relating to the potential that this model has to lead to sustained improvements in health outcomes vis-à-vis other envisaged models. And the answer to this can only be provided by evaluation to determine what gives the best value for money and is most equitable. The model centered on ‘contracting management’ may appear suitable in some areas owing to the concomitant presence of NGOs with the ability to deliver in such arrangements whereas other districts my choose to have other revamping options based on local adjustments.
What are the imperatives for institutionalizing the RYK model?
Any new initiative emerges as a creation; if the idea comes forward from within the establishment, it gets institutionalized at inception. However if it is a product of thinking within the civil society or technocrats – which then acts as a catalyst for change – it may take a while for it to get implemented or to institutionalize. Within this context, PRSP as an NGO took the lead in the process and clearly they qualified to be the initial partners. However systems interventions carried out by civil society organizations must be institutionalized when taken to scale. And now that there are public statements to support the up-scaling of the pilot project, consensus of the professional and public health community and its citing within an explicit policy framework become an imperative. This exercise must also carefully bear in mind questions relating to mandates, prerogatives and responsibilities at the federal-provincial interface with reference to policy making. Within this context therefore, careful attention needs to be paid to the following considerations: Firstly, getting the main stakeholders i.e. Ministry of Health and provincial departments of health on board and signaling of a clear policy position from the Federal Ministry of Health on the available options for restructuring BHUs, albeit giving provinces flexibility to choose what they think is most locally viable. Secondly, analysis at the provincial and district level of what is most suited for their needs and works best based on outcomes and financial analysis. Thirdly, in the event of restructuring within the existing systems, linking in with mechanisms that have already been set up such as the National Commission for Government Reform. Fourthly, guidance for provinces and districts that choose to contract out services in the areas of competitive selection processes. In the fifth place the stipulation of a minimum package of services to be delivered through the contracted out facilities and their means of monitoring and evaluation. And lastly, a reconfiguration of the State’s institutional ability to regulate the delivery of services by the private sector, because in the new contracting out models, the state will be the regulator and financier of services but not the provider as opposed to the earlier situation where it was all three.
What are the structural imperatives in the event of adopting the contracting out arrangement for restructuring BHUs?
Work needs to be initialized on a number of macro-structural issues in order to institutionalize the contracting of BHUs. Firstly, frameworks for public-private partnerships need to be developed; secondly, capacity of provincial and district governments needs to be enhanced in order to manage service delivery contracts; thirdly in the event of a fee for service being introduced in the contracted out sites, a mechanism of social protection has to be mainstreamed to ensure that public funding offsets the risk to the poor through waiver and exemption mechanisms. Fourthly, another structural imperative is to integrate community co-management at a basic healthcare level. The concept of having a community-based body at the facility level to oversee management and quality issues is now realistically possible, given the focus on community development and mobilization as part of the devolution initiative. Fifthly, the referral chain of contracted out facilities, which will then be in the private sector with RHC/THQ in the public sector need to be defined and streamlined. And lastly, the institutional arrangements for handling the BHUs restructuring program will have to the defined. BHUs until recently were controlled by the District health departments; however we now see the emergence of a different lines of reporting to a high level institutional arrangement. The prerogatives of this with the State health machinery will have to be defined at the provincial level and the manner in which this will regulate the delivery of services through contracted out partners will have to be clarified.
What are the public health imperatives of contracting out BHUs?
The contracting out option of restructuring BHUs also underscores the need to define the mechanisms of the delivery of preventive public health services which the state presently delivers through these sites and which must be delivered as a public good. Notwithstanding major issues in their present form, BHUs and RHCs serve as community hubs for the delivery of preventive and promotive services such an vaccination and control of infectious diseases; in addition, BHUs also serve as hubs for Lady Health Workers including training, reporting etc. In facilities where management is contracted out the State must define mechanisms for the delivery of health-related public goods and priority services and its new operational role in these models and explore whether these programs can be part of the package for which the management organizations is responsible for.
In summary therefore, the RYK Model of contracting out basic health facilities offers one restructuring option for galvanizing the States primary health care infrastructure into action; contrary to popular belief, it does not involve privatization of facilities, franchising or the introduction of a fee for service. Notwithstanding its weaknesses, the model has its merits and the impetus that it provided to alternate service delivery arrangements needs to be appreciated. However given that there may be other options for enhancing the functioning of BHUs which gel with the administrative prowess of the devolution initiative, restructuring decisions should be based on what is locally guided by evidence. A system for restructuring BHUs must also have appropriate checks and balances fro ensuring sustained improvements. Ideally there should be a role for management in these arrangements, which can be taken by the party to which work is contracted out; a role for quality assurance and evaluation which can taken up by State agencies, who must have appropriate capacity for this purpose and a role for community oversight, which can be served through linkages with the devolution initiative.
The challenge at the policy level now is to articulate a clear policy position on these matters with stakeholder, institutional and professional buy in and with the active involvement of the Ministry of Health and the departments of health as per constitutional prerogatives. Within this entire paradigm, the contribution of the NGO in serving as a catalyst for change should be lauded. But now is the time for mainstreaming this through the State’s institutional mechanisms – regardless of how weak they are – for it is ultimately the responsibility of the State to deliver health and it is only by strengthening their ability to do so that the civil society’s unwritten mandate can be truly served.
The author is the Founder President of the NGO Heartfile and Pakistan’s Health Policy Think Tank/Forum. E mail: sania@heartfile.org
Playing health with a new stack of cards
Published in The News International on July 02, 2006:
‘Playing health’ with a new stack of cards
The planet earth’s environmental and ecological transformation is a subject of much ado as are the contemporary concerns around the power dynamics, which will determine the global epicenter economically, militarily and politically over next two to three decades. This is justifiably a subject of critical thinking and planning. But sadly, the implications of this makeover for the social sector remain largely unrecognized. In the health sector more specifically, the thinking that health needs to be delivered as a public good – modeled on the Alma Ata ethos – still holds ethical merit backed by constitutional legitimacy and state commitment as in many developing countries; this model is also being followed in Pakistan where the delivery of health is seen as a state prerogative with the state attempting to provide health for all. How the booming market dynamics play into this calculation, how vested interests, profit margins and the omnipresent role of the private sector cut across this paradigm, how a globalized world impacts access and affordability issues in health and how urbanization and an aging population necessitate new demands for health care is seldom a focus of attention. It is time that these considerations are a focus of concerted planning or else health will fail to reap the benefits of economic growth on which Pakistan appears to have set forth recently.
There are several reasons why the health sector needs conceptual restructuring.
Firstly on issue of the viability of the state-delivery-of-care-model, it must be understood that broader changes in the macro-economy and the emergence of the private sector as the engine of growth have also led the private sector to offer what is regarded as ‘social services’ by the State – albeit at a cost. We are aware that the level of incentives to offer care in the private sector have led to the institutionalization of dual job holding by health professionals; these considerations have systematically undermined the State’s health service delivery infrastructure: basic health units do not function because of a lack of motivation to operate them and hospital high tech equipment is often out of use because of lack of incentives to operate them. On the other hand, quality issues notwithstanding, we see the private sector – infrastructure as well as human resources – booming and delivering care in the market for a cost in an environment which is largely unregulated.
Secondly, globalization has brought in its wake many contemporary challenges. The technology boom and the speed and access to interconnectedness has created a huge opportunity for capacity building, streamlining quality and efficiency in the delivery of care and management, and knowledge sharing but on the other hand also the risks of spurring costs as a result of over-utilization especially in the unregulated private sector. Liberalization of trade under WTO in a globalized community brings its own access and affordability issues particularly in terms the affordability of newly discovered medicines and under GATS, the mainstreaming of the market mechanism in the delivery of care in a manner that is detrimental to the interests of the marginalized, is a potential threat. In a globalized world, pandemics are known to spread with relative ease as have the SARS and Avian flu epidemics shown and mass damage by biological weaponry and humanitarian crises as a result of conflict and acts of terrorism are known to have health implications.
Thirdly, over the years, evidence has shown that health is not all about what the health sector can deliver. For instance, the most successful intervention to reduce child mortality is not related to the number of hospitals or doctors but investments in the mother’s level of education; the most effective intervention to reduce tobacco related morality is tax, tarrif and price related and the most effective intervention to reduce childhood diarrhea is in the municipal and not the health domain.
And lastly, demographic and epidemiological transitions in health are known to reshape the way disease patterns will affect populations and the manner in which population subgroups will be affected, raising concerns about the current priorities for resource allocations.
How should the health sector be responsive to these realities and what should the role of the state be then over the next two to three decades? Should it attempt to continue to act as a part-financier, part-provider and quasi-regulator of health services or should it relinquish control of the role of being the provider and enhance its capacity to regulate a market, which has every intention of growing, regardless? Should it operate a “health care” paradigm or should it broaden its scope within an inter-sectoral ambit and focus on the inter-disciplinary responses as well. Should it focus on improving health outcomes through a focus on doctors, hospital beds, and other health care outputs or should it address health within a broader international and national policy context. Clearly the choices are and should be clear. The logical next question is how to respond and what works then?
Over the years we have learnt that coercive responses to this reality are not going to work; amongst other things, this has also been recently demonstrated by the failure of institutional based private practice in NWFP; we have also seen that the adhoc institution of measures such as contracting out models seem to generated a widespread outcry and controversy with issues of acceptance and turf battles. It is therefore clear that piecemeal solutions to a paradigm which has completely changed will not be sufficient; this underscores the need to ‘play health with a new stack of cards’. We need to define new norms and standards, redefine the role of the state in the provision of care, strengthen its ability to regulate, broaden the base of the civil service reform process to a public sector reform process alive to these realities; enable the creation of frameworks that both regulate and facilitate the private sector and create strong institutional frameworks to offset the risk to the poor and disadvantaged in an environment where health is being increasingly sold for a cost. It is here that the responsibility for redefining the ‘rules of the game’ fall on initiatives such as the recently launched Vision 2030 – a valid foresight exercise of the Planning Commission of Pakistan designed to assist in defining the needs of a future Pakistan. The program gives due prominence to health through its ‘prosperous society sub-theme’ on health care and social sector. It is hoped that this initiative will articulate, strategic directions to address the aforementioned issues. However as always, the challenge then would be to ensure these get concretized into implementation – in letter and in spirit.
The author is the Founder President of Heartfile and Pakistan’s Health Policy Think Tank. E mail sania@heartfile.org
Budget 2006-07 – an ode to health
Published in The News International on June 30, 2006:
Flagging a 21.3% increase in the budgetary allocation for health as part of the unprecedented increase in the development expenditure in the fiscal budget of 2006-07, the recital of June 5, 2006 made a reference to health as being a provincial subject.
True that health is a provincial subject and true that the provinces – and now under the Local Government Ordinance of 2001, the Districts – have legal responsibility to deliver services. But then the federal government has constitutional prerogatives relating to health, which have important fiscal implications both at the provincial and district levels as well as within the overall ambit of federal programs in the health sector.
Evidently, increases in budgetary allocations are a sine-qua-non of improving health outcomes. But clearly not the only! As the most complex of the social sectors, health necessitates in tandem systems and financing restructuring, for which budgetary allocations can act as the key tool in addition to being the critical input. With this as a context, three questions have been addressed within the context of the recent increases in budgetary allocations for health.
The first question relates to whether improvements in health outcomes can be achieved with aggregate increases in budgetary allocation, per-se?
Utilization issues notwithstanding, the total public sector health expenditure was shown to double in the period 1991/92 to 1997/98 with a 100% increase over the last five years and a further 21.3% increase this year. Admirable indeed. However firstly, it is imperative for this to continue and with sharper increments so as to bridge the current disparities in health expenditures particularly with reference to regional comparisons. Secondly, While this is vital, it also needs to be emphasized that specific aspects of health systems development are a stronger determinant of health status achievement compared with total health expenditure; budgetary allocations should therefore be viewed and used as a tool with the realization that they can assist in enhancing the performance of the health system by transforming the management of individual facilities, the management structure of the staff and the institutional environment in terms of the capability to plan and deliver.
Thirdly, it is imperative to underscore the importance of fund utilization. Issues with fund release, their utilization and the resultant budgetary lapses are well recognized. And it is here that striking a balance between minimizing costs, controlling costs and using resources more efficiently and equitably – in other words, getting the best value for money, on the one hand, and increasing the pool of available resources, on the other, becomes important. Specific interventions such as the promotion of transparent financial administration, budgeting and cost controls and enhancing the capacity to overcome onerous financial management procedures, decentralizing decision-making and ensuring accountability are relevant. Though these efforts have been initialized under the umbrella of civil service and other reform measures, they need to be expanded to the public service context in order to comprehensively impact health – and indeed social service delivery.
Fourthly, budgetary increases should be viewed in the context of inflation and population growth and the real per-capita expenditure; with respect to allocations per-se, it is not just the aggregate increase but the ratios between the development and non-development budgets, allocations for prevention vs. cure and the balance between financing interventions for rural vs. the urban areas, which need to be taken into account. Trends have been comparatively favorable in relation to the ratio between development and non-development budgets at the federal level over the last 10 years but the provinces have shown a worrying trend with a major dominance of non-development budgets in the provinces – a gap which seems to have widened over the years. Prevention and cure disparities are evidenced in the successive Five Year Plans, where clinical services have consistently consumed more than 45% of the total health budget as well as in provincial budgets where more than 50% of the budgets are allocated for teaching hospitals. Along the same lines a balance between financing health in the rural vs. the urban areas should be an area of concerted focus not only for the conventional adage – seventy percent of Pakistan’s population lives in the rural areas – but also given that recent surveys have reported significant rural-urban disparities in key indictors. For example, the Under-5 Mortality Rate in the rural areas of Sindh has been reported at 117 compared to 68 in the urban areas and 55 per live births in the city of Karachi. Some of the aforementioned allocation discrepancies are within the provincial domain on which a contemporary commentary may be presumptuous given that recent data on these – pending the provincial budgets of 2006-07 – is not available and in any case these are provincial matters, indeed. However, the federal allocations can signal the importance of distributions in certain areas through its financial instruments such as the conditional grants or through certain policy measures, albeit with provincial buy in.
The second question relates to the federal and provincial roles and prerogatives and the manner in which these create impediments and opportunities particularly with reference to the fiscal interface?
Under the Constitution and the rules of business, which clearly defines roles and responsibilities, both of the provinces as well as the Federation in health, the Federal government is mandated with responsibilities for policy-making, legislation, coordination, resource distribution and acquiring foreign assistance whereas the provincial ministries have legal responsibility for delivery and management of health services; however provinces can also legislate in many areas under the Concurrent Legislative List. Within this framework, the Federal Legislative List opened avenues for the Federal Government to create institutes and hospitals on provincial territory and develop national programmes that are ‘integrated’ with the provincial health delivery systems.
Allocation decisions for the provincial health budgets are made by the provinces independently out of the provincial development budgets, which are financed by the federal government en-bloc through the National Finance Awards as unconditional federal grants. Provincial non-development budgets are, in theory, funded from provincial government revenues. During the SAP years, part of the recurrent budget was also made available by the federal government; however, this has since been largely discontinued. However, the Federal Government also supplements provincial development budgets through conditional or tight grants and in contrast to the former this enables the federal government to allocate resources in specific areas such as in the case of the federally-led public health programs.
However over the years, despite these stipulations being straightforward, overlapping services have created ambiguities between federal and provincial roles and responsibilities and administrative authority; these issues have been compounded by conflicts over sharing of resources and financial arrangements. Owing to these problems, the federal-provincial interface has become one of the overarching systems-level thorny issues in the health sector – a problem, somewhat ‘complicated’ further after the passage of the Local Government Act.
It is perceived that gaps in understanding provincial requirements and/or prerogatives create problems with budgetary allocations. These and other considerations also create issues with the implementation of federally-led public health programs in the provinces. At a provincial level, it is perceived that federal programmes do not clearly analyze their implications on overall recurring costs. Moreover there is a certain level of lack of ownership of federal public health programs at the provincial level; the recent reluctance on part of Punjab to sign up to the Maternal, Neonatal and Child Health Program along the lines of the centrally funded initiative is a case in point and highlights the need to use the budget as a financial instrument for enhancing provincial performance and stimulating innovation, even if it means radically reconfiguring some programs.
Now the third question of why the need for alternate modes of financing health when the budget is on the way to being increased?
It is important to recognize that this would be a strategic imperative. Pakistan currently principally uses three modes of financing health – taxation, out of pocket payments and donor contributions of which the latter is the least significant in terms of size. The total per-capita health expenditure in Pakistan is reported to be between Rs. 750 to 800; while no official figures exist, experts believe that 25% of this is contributed by the public sector and 75% through private out-of-pocket fee-based funding mechanism (Pak. Rs. 570). However, a number of considerations warrant that we revisit this paradigm for a number of reasons.
Firstly, taxation as a mode of financing health demands an extensive tax collection capacity and is possible largely in formal economies. In Pakistan, the informal sector of the economy is predominant and general taxation accounts for less than 20% of the GDP. In all likelihood, judging from the current trends, it is most likely that the volume of economic activity will increase and if the current growth is sustained and the population moves into the formal sector, the tax base and taxation capacity of the country will broaden; however, meanwhile, alongside efforts to reallocate existing tax resources for health other options will have to be considered.
The second major mode of financing health is out of pocket payments. The monthly household out-of-pocket expenditure on health has been reported at Rs. 358. This is equal to 5.2% of the total monthly household expenditure and translates into an annual per-capita health expenditure of Rs. 570 – clearly a significant burden for 23.9% of the Pakistani population which according to the recent poverty estimates lives below the poverty line. This highlights the need to mainstream social health insurance as a mode of financing health. In all fairness, budget statements such as “the government is using its resources to reduce difficulties for the deserving citizens” and “to provide non invasive Angiography, MRI and dialysis to deserving people free of cost at federal government hospital, latest machinery is being provided” are evidence of the commitment to strengthen safety nets for health service delivery for the disadvantaged; however, these will have to be carefully structured. Importantly within this context, the recently launched Social Protection Strategy needs to be revisited to broaden its scope on health given that the only area where it alludes to health is in the section on employees’ social insurance which is just one dimension and that too for the formally employed.
Social health insurance also necessitates feasible and pragmatic organizational management to boost pre-payment and build enabling mechanisms for the development of a large pool of fund for which a number of steps need to be taken. As a preliminary step, the budget could have signaled the importance of this through the creation of a Health Fund, which would have indicated the government’s commitment to providing per-capita cost-sharing in subsequently launched social health insurance arrangements; following this the feasibility of channeling Zakat funds and philanthropic grants into such a fund could have been explored.
The third source of health financing has been donor contributions; foreign aid as a percentage of total health sector allocation has officially ranged from 4-16% over the last several years. However, over the long term there should be a shift away from reliance on donor contributions given that they bring in their wake many challenges; for a start, donor contributions prioritize resource-allocations in specific programme-based areas rather than systems-strengthening interventions, which are the need of the day; undue reliance on donor resources can be detrimental to programme sustainability as donor support is generally dependent on political and general conditions prevalent geographically.
In the fourth place, changes in the public-private roles, which are interlinked with the broader changes in the macro-economy merit consideration; within this framework, it is crucial to develop health financing options which are alive to contemporary realties on the one hand and protect the interests of the disadvantaged to which the state is committed to provide health as a public good – as it should. The contribution of the private sector to health cannot be ignored if public and private expenditures on health as a percentage of GDP are taken into consideration. The government currently spends 0.8-0.7% of its GDP on health whereas the total expenditure can roughly be placed at 3.5% of the GDP. These considerations necessitate, exploring mixed arrangements for the delivery of health.
Above all it must be recognized that the health financing patterns are shaped by the macroeconomic environment not only because they can enable the allocation of more resources but also because they can reconfigure how financing patters are determined; the recent example of countries where economic booms have created opportunities for global employment practices thereby creating an environment where employers subscribed to health benefits is a case in point. It is hoped that as Pakistan economically prospers, such new options will become available. However the policy challenge then would then relate to how well these match against considerations of equity given that after all, health – at least some priority services – should be delivered by the State as a public good.
Moreover it is hoped that in years to come the social sector and options for strengthening delivery would be centre stage during the pre- and post-budget deliberations as it is only through an increase in the demand for these services that the State will be more responsive to the need for strengthening them.
The author is the founder and president of Heartfile and Pakistan’s Health Policy Think Tank. E mail: sania@heartfile.org
The Health Budget 2006 – the policy context
Published in The News International on June 06, 2006:
Budget 2006 is just around the corner with an indication that there would, both, be aggregate as well as program-specific enhanced allocations for health. This raises the question of whether these can translate into improved health outcomes over the short term. Here it must be understood that the relationship of health indictors does not necessarily parallel the level of resource inputs particularly if considerations relating to the utilization of funds and a reconfiguration of the health system are not brought to bear. Within this context, three questions emerge: how should we interpret and analyze the current allocations – per se; do we need to focus on how budgets can be utilized better and do we need alternate modes of health financing, and if so, why?
Firstly, interpreting the ballpark figures: the Government of Pakistan has been spending 0.6 to 1.19% of its GDP and 5.1 to 11.6% of its development expenditure on health over the last 10 years. However, these figures reflect spending by the Ministry of Health and the departments of health and do not take into account other public sector health services, and the private sector; if these are taken into account, the total expenditure can roughly be placed at 3.5% of the GDP. Utilization issues notwithstanding, the total public sector health expenditure was shown to double in the period 1991/92 to 1997/98 with a 100% increase over the last five years and a probable increase this time round. However, budgetary increases should be viewed in the context of inflation and population growth and the real per-capita expenditure. Enhanced allocations must also favorably impact the ratio between development and non-development budgets. A comparison of the 2003/04 and 2004/05 federal and provincial development and non-development budgets shows a major dominance of non-development budget in the provinces. This gap appears to have widened over the last 10 years whereas at the federal level, trends have been comparatively favorable. Budgetary allocations for health must also factor a favorable ratio between prevention and tertiary care allocations; within this context, a comparison of the primary healthcare budgets with clinical health programme budgets in successive Five-Year Plans shows that clinical services have consistently consumed more than 45% of the total health budget. Along the same lines a balance between financing health in the rural vs. the urban areas should be an area of concerted focus not only for the conventional adage – seventy percent of Pakistan’s population lives in the rural areas – but also given that recent surveys in 2005 have reported significant rural-urban disparities in key health indictors. For example, the Under-5 (years of age) Mortality Rate in the rural areas of Sindh has been reported at 117 compared to 68 in the urban areas and 55 per live births in the city of Karachi.
The second question relates to why we need to focus on the utilization of budgetary allocations. This is simply because issues with fund release, their utilization and the resultant budgetary lapses are well known. And it is here that striking a balance between minimizing costs, controlling costs and using resources more efficiently and equitably – in other words, getting the best value for the money, on the one hand, and increasing the pool of available resources, on the other, becomes important. Specific interventions such as the promotion of transparent financial administration, budgeting and cost controls and enhancing the capacity to overcome onerous financial management procedures and decentralizing decision-making become important. There is also the need for greater financial procedural clarity at the federal-provincial district interface.
The third question relates to why there is a need for alternate modes of financing health when the budget is on the way to being increased? It is important to understand why this is so. Pakistan currently principally uses three modes of financing health – taxation, out of pocket payments and donor contributions. However, ground realties warrant that we revisit this paradigm for a number of reasons. Taxation as a mode of financing health demands an extensive tax collection capacity and is possible largely in formal economies whereas in Pakistan the informal sector of the economy is predominant. It is likely that as the volume of economic activity increases and if the current growth is sustained the population will move into the formal sector and the tax base and taxation capacity of the country will broaden; however meanwhile, alongside efforts to reallocate existing tax resources for health other options will have to be considered.
The second major mode of financing health is out of pocket payments. The total per-capita health expenditure in Pakistan is reported to be between Rs. 750 to 800; while no official figures exist, experts believe that 25% of this is contributed by the public sector and 75% through private out-of-pocket fee-based funding mechanism (Rs. 570). The monthly household out-of-pocket expenditure on health has been reported at Rs. 358 in Pakistan. This is equal to 5.2% of the total monthly household expenditure and translates into an annual per-capita health expenditure of Rs. 570; this is clearly a significant burden for a sizable chunk of the Pakistani population which lives below the poverty line. Cleary this highlights the need for mainstreaming social health insurance as a mode of financing health; within this context, the recent Social Protection Strategy needs to be revisited to broaden its scope on health given that the only area where it alludes to health is in the section on employees social insurance which is just one dimension and that too for the formally employed.
The third source of financing health has been donor contributions; foreign aid as a percentage of total health sector allocation has officially ranged from 4-16% over the last several years. However, over the long term there should be a shift away from reliance on donor contributions given that they bring in their wake many challenges; for a start, donor contributions prioritize resource-allocations in specific programme-based areas rather than systems-strengthening interventions, which are the need of the day; undue reliance on donor resources can also be detrimental to programme sustainability given that donor support is generally dependent on political and general conditions prevalent geographically.
Given these considerations alternate sources of financing health are now a strategic imperative; there are many already many existing sources within Pakistan which need to be further built upon. For instance we know that the employees social insurance which currently secures 3.06% of the workforce can be broadened; philanthropy through Zakaat and Bait ul mal, which has contributed less than 3% to public contributions in health, can be mainstreamed by structuring a conducive tax configuration and that corporate support can be mobilized within the framework of corporate social responsibility, albeit with safeguards.
Above all it must be recognized that the health financing patterns are shaped by the macroeconomic environment not only because they can enable the allocation of more resources but also because they can reconfigure how financing patterns are determined; the recent example of countries where economic booms have created opportunities for global employment practices thereby creating an environment where employers subscribed to health benefits is a case in point. It is hoped that as Pakistan economically prospers, such new options will become available. However, the policy challenge then would then relate to how well these match against considerations of equity given that after all, health – at least priority services – should be delivered by the State as a public good.
The author is the founder and president of Heartfile and Pakistan’s Health Policy Think Tank. E mail: sania@heartfile.org
The Public-private interface: more than – a driver of economic growth
Published in The News International on May 28, 2006:
Changes in public-private roles are interlinked with broader changes in the macro-economy. Limitations of centrally planned economies, the resultant privatization of State-owned enterprise accentuated by fiscal constraints and donor conditionalities have continued to promote a package of measures in the developing countries, which make private sector the engine of growth. The current Government of Pakistan polices hinge on this concept and have forged ‘partnerships’ with the private sector in order to finance infrastructure needs of the country and open new sectors on the premise that the role of the State is to provide a policy, regulatory and legal environment. Within this context the recent title of Pakistan’s Development Forum “Drivers of Economic Growth: Unleashing the Potential of the Private Sector” was relevant given that it underscored the realization that many considerations have – and will continue to – automatically move back the borders of the State, reshaping the way the government does business.
However, it must be recognized that these considerations also impact the discourse over public goods and the role played by governments in financing and providing social services – health and education, in particular. And it is here that another dimension relating to “unleashing the the private sector”– one that draws the social sector into the debate – is of relevance. Exploring different mixed arrangements for the delivery of public good does not mean changing the roles of the Government but transforming it. It is hoped that future gatherings of the Pakistan Development Forum will expand their focus to this broader and more appropriate context of public-private roles and opportunities and will ensure adequate representation of stakeholders given that a discourse over this transformation takes more than the development partners and the government and in view of the fact that one of the key stakeholder in this arrangement is the indigenous civil society!
Public-private relationships range from interface arrangements, privatization, contractual roles, to true partnerships. The latter being long-term task-oriented arrangements that bring together organizations with the mandate to offer public good on the one hand, and those that could facilitate this goal though the provision of resources, technical expertise or outreach, on the other. A variety of combinations can emerge to serve a number of purposes when the public sector comprised of governments at various levels and/or multilateral agencies vis-à-vis the private sector, which consists of for profit and non-profit entities, are interfaced.
Extrapolated to a health sector context, and limitations notwithstanding, a range of partnerships can be cited from within Pakistan where the public-private mix works together for service delivery, enhancing outreach, in governance arrangements and in strategic planning. For example, Pakistan is involved in many transnational partnerships such as GAIN, GAVI , STOP TB and Roll Back Malaria for improving access of populations to products and services. At a service delivery level, the recent strategy to revamp the Primary Health Care System is based on a public private model where services are contracted out to NGOs at a basic health care level. Partnerships have also been forged for the delivery of preventive programs, as in the case of the National HIV/AIDS and Malaria control programs. Examples of outreach enhancing partnerships are the EPI programs’ use of private sector field force to augment polio day campaigns and the social marketing partnerships with Green star, Key Social Marketing and Marie Stopes for improving contraceptive use. Partnerships with NGOs with technical capabilities such as with Marie-Adelaide for leprosy control and Heartfile for non-communicable disease control are also well established. The public private interface can also be galvanized at a governance level; representation of the private sector on hospitals boards such as in the case of SIUT and Kidney Center in Karachi and other hospitals is an example; at a grass roots level, public-citizen partnership can be formed at the level of Citizen Community Boards and Village Health Committees as part of the Devolution initiative. Public private relationships can also be forged for resource mobilization; these allow governments to tap into corporate resources and enable the commercial sector to fulfill its social responsibility. The recent contributions of Merck Marker to renovate and upgrade the Emergency of PIMS hospital is an example of an infrastructure related contribution; Novartis pharmaceuticals’ contribution of Rs. 1.5 billion in the year 2005 to provide the anticancer drug Glivec under its Glivec International Assistance Program is an example of contributions for improving access. The private sector interface for health financing also has the potential to restructure the manner in which services are delivered. The State currently models health care delivery on tax revenues and out-of pocket payments; this base can be broadened by mainstreaming the role of private insurance industry, enhancing the coverage of the Employee’s Social Security Scheme and mainstreaming health in the recently launched Social Protection Strategy. Furthermore, the recent creation of the Heartfile-hosted Health Policy Forum is yet another example of a civil society led effort which serves as the first health think tank in the country and contributes to strategic planning at a policy level.
It is well established that leveraging the potential of the private sector partners can significantly improve outcomes across a range of social services and can enable
the State to share responsibility for getting programmes out to communities by relying on groups and organizations that have complementary mandates. These arrangements present a very powerful mechanism for leveraging the strengths of various partners; however caution needs to be exercised given that the idea is not to privatize public responsibilities but to strengthen safety nets. Careful attention therefore needs to be paid to ethical, conflict of interest related, methodological, accountability, sustainability and governance issues in such relationships. In line with this there is a need to develop norms and standards which stipulate certain criteria in relation to the relevance of partnerships to the overall goal of development. In addition, there is also the need to strengthen and update policies, legislative frameworks and operational strategies that legitimize and give clarity to the roles and responsibilities of the public and private stakeholders in combined models.
The Punjab Government has drafted a law – the Punjab Private Participation in Infrastructure Development Act – which lays down a statutory framework and procedures for formalizing the participation of the private sector in building infrastructure in the province. According to their website, the law will come into force after approval by the provincial cabinet and assembly. However, this law and the institutional mechanisms which it will create – the Punjab Infrastructure Regulatory Authority – are primarily relevant to building infrastructure and outlining contractual agreements on the basis of BOT, BOO and ROT – expressions that have been referred to in the Medium Term Development Framework. However, legislation on public-private relationships needs to be more overarching and applicable at a country level. The role of the recently created Infrastructure Project Development Facility under the auspices of the Ministry of Finance can be important in this regard as it can play an important role not just by providing timely and easy access for PPP implementing agencies but also preparing and managing PPP projects in the country in view of the aforementioned broader considerations.
The impetus for driving efforts in creating a transparent and conducive environment for public-private partnerships needs to come from the public sector. This raises the issue of capacity and highlights the need for gaps in capacity to be bridged as a priority – particularly with respect to regulation given that the success of public private partnerships lies in the ability of governments to transparently regulate such arrangements. It must be recognized that the results of such actions will only be as good as the Government intends to make them and therefore, it must have a strategic outlook in attempting to yolk the private sector to their own cart.
The author is the Founder and President of Heartfile and Pakistan’s Health Policy Think Tank. E mail: sania@heartfile.org
Global Consortium on Community Health Promotion.
Nishtar S, Perry M, Lammare MC, Ritchie J. Global Consortium on Community Health Promotion. Promotion and Education 2006;XIII(1):7-8.
Social Health Insurance in NWFP – the steps ahead
Published in The News International on April 30, 2006:
A news feature in The NEWS on April the 4th has outlined the NWFP Department of Health’s intent to launch a social health insurance scheme for the province. Aimed at improving access of the marginalized to health services, this is, in principle, a step in the right direction as it potentially offers a ‘health systems’ rather than an ad hoc solution. It is envisaged that if the strategy is appropriately structured, it can obviate some of the equity issues that have arisen from the currently prevailing tertiary-care-heavy health financing patterns. The articulation of this intent is also reflective of a bilateral donor agency’s proactive role in supporting health reforms and the strategic institutional support they have provided to the NWFP Health Sector Reform Unit, which amongst other things has primed policy makers to systems solutions. While the NWFP Department of Health needs to be lauded for it’s out-of-the-box thinking, it is also opportune to remind them of some of the overarching considerations that must be borne in mind while they embark upon mainstreaming social health insurance as a form of health financing in NWFP.
Firstly and to set the context, it must be recognized that social health insurance is just one component of a social protection strategy and must be approached within its framework. However, there are several design and implementation challenges in structuring a social protection mechanism outside the formally employed sector given that this necessitates overarching policy and legislative commitments, which are largely outside the scope of the health sector. It is imperative that the Department of Health recognizes the need for building linkages to address these issues earlier on so as to have this strategy housed, hoisted and pitched at the right level. It would also be important to build broader linkages outside of the province to harness the strength within other similar initiatives. For example a Steering Committee has been constituted by the Planning Commission on social protection and work is presently underway by the World Bank, ADB and DFID to provide coordinated technical support to the Government of Pakistan in the area. Furthermore, the Asian Development Bank’s Country Strategy Programme for Pakistan (2004-2006) foresees technical assistance for social health insurance in 2005 with the objective of supporting the government of Punjab’s task force in its efforts in the area of health insurance on the one hand, and deliberating with the Ministry of Health on the subject, on the other. Clearly these are opportunities for coordinated planning.
Secondly, it would be critical for any de novo effort in the area of health insurance to link-in with and build on existing systems which finance health on insurance arrangements in NWFP. Notable amongst these is the Employees Social Security Scheme – which is a health insurance scheme, limited to the formally employed sector, where contributions can be made through salary deductions at source. It would also be important to learn lessons from failed experiences in the past such as in the case of the unsuccessful health insurance pilot in NWFP, which led to the withdrawal of funding support by World Bank and JICA.
Thirdly the establishment of a broad-based comprehensive mechanism for social protection, which can provide a safety net for the poor, would necessitate strategic attention to a number of institutional, fiscal and regulatory considerations. A health insurance institutional mechanism will have to be established and a legal and policy framework will have to be created for this purpose. Amongst the regulatory parameters that merit attention includes approaches to membership for populations and the extent of health cover to be provided; the latter is important given that government funds should preferentially be used for insurance models that cover for priority healthcare. This in turn highlights the need to define priorities and underscores the need for strengthening the normative health policy roles and bringing clarity to federal and provincial roles and prerogatives in health care delivery. Regulation will also have to ensure that this model reinforces and does not undermine the referral system.
Social health insurance also necessitates feasible and pragmatic organizational management to boost pre-payment and build enabling mechanisms for the development of a large pool of fund. A number of steps will have to be taken to achieve this objective. As a preliminary step, a sustainable Provincial Health Fund will have to be created with the government’s commitment to providing per-capita cost-sharing and the feasibility of channeling Zakat funds and philanthropic grants into such a fund will have to be explored. Such a fund will need to be protected by investment strategies, to ensure that inflation does not eat into its operational resources; it would be most interesting to observe how the current government of NWFP deals with this reality given their overarching policy positions on various issues.
Fourthly, social protection must be seen in a conceptual and ideological context. In Pakistan’s health care systems the state has traditionally attempted to provide health for all. Currently the State is attempting to redefine its role in service delivery through the introduction of alternative models of service delivery that mainstream the role of the private sector. This approach brings efficiency into the system but may raise concerns relating to access and affordability for the poor. And it is within this context that social protection becomes imperative. Conceptually therefore, social protection has to be pitched alongside other comprehensive health systems reform measures. What is happening in NWFP by way of channelling social protection as a mode of health financing and in Punjab by way of restructuring service delivery should ideally proceed in tandem within the same health system. Perhaps NWFP and Punjab Departments of health can capitalize on this opportunity for collective strategic thinking that may be applicable in both settings.
There can be no two thoughts about the need to pay careful attention to setting up a social protection system, given that Article 38 of the 1973 Constitution of Pakistan makes it binding for the state ‘to provide basic necessities of life for all citizens as are permanently or temporarily unable to earn their livelihood on account of infirmity, sickness or unemployment’. Social protection is also an imperative in view of the increasing role of the market mechanism in the delivery of health service as a whole and the mainstreaming of private sectors role in state-owned infrastructure more specifically. Within this context, NWFP’s initiative is both timely and needed. However it would need long term planning, strategic positioning and careful structuring within an overall health reform context in order to fly.
The author is the Founder President of the NGO Heartfile and Pakistan’s Health Policy Think Tank. E mail: sania@heartfile.org
Civil Service Reforms–the move from hype-to-hope
Published in The News International on April 09, 2006:
Civil service reforms need to be an integral part of social sector reform processes if sustainable solutions to currently existing issues within the ambit social sector service delivery are envisaged. Within this context, there seems to be some justification for the perception that civil service reforms may finally be part of a mainstream agenda in Pakistan. This is evidenced by the initiation of processes such as the creation of a Committee for Civil Service reforms, the establishment of a Civil Service Reform Unit in the Establishment Division, launching of the Professional Development Agenda and the more recent announcement of the reform package for introducing good governance in the country by the Ministry of Law and signaling the importance of this area of reform by soliciting help from the multilateral development agencies. However, given that this is not the first time efforts are underway in this area, tipping the balance from the hope-to-hype equation will depend on the manner in which a strategic approach prevails – both in intent and in actions. Within this context, five points are worthy of consideration.
- Bridging the colonial-contemporary lag: modeled on the colonial system, the core functions of Pakistan’s civil services are administrative control, collection of revenue, exercising control through regulatory checks and in the case of its expanded definition to public services, active engagement in service delivery. Exceptions notwithstanding, this model has little relevance to the problems of the public sector today which relate to harnessing the entire resources of the economy towards the goal of development. The public sector’s limitations – owing to lack of resources and management issues – therefore underscore the need to develop interface arrangements, with organizations that could facilitate achieving this goal. Such interface arrangements, which have to do with establishing partnerships with the private sector for providing sustainable outcomes warrant a paradigm shift in reconfiguring the role of the public sector. This would entail ‘exercising administrative control’ through participatory decision-making in evidence-based frameworks, ‘enforcing regulation’ through setting of standards, an unbiased approach to ensuring compliance with these standards and assurance through strengthening peer organizations as we move to new models of financing and delivering services and implementing frameworks for public-private partnerships. This would require major institutional changes in the present arrangement of civil service operations. Reconfiguring to meet this goal is the first challenge that the civil service reforms will have to address.
- The incentives-accountability-performance nexus: many a times, civil service reforms are considered as being synonymous with incentive building. Clearly incentives – albeit linked to performance – must be a priority to bridge the current disparity between the current public-sector salaries and the public-sector-accepted-market-rate for professionals, which is evidenced by what consultants ‘within’ the public sector are offered. However, it must be recognized that lack of capacity is clearly a constraint on the ability to act on these incentives. This highlights the need for instituting appropriately tailored capacity-building programs in tandem with Recruitment, Promotion and Pay and Pension Reforms currently on their way to being implemented. However, capacity building must be needs-based and targeted. The current three-pronged capacity building initiatives inclusive of the Professional Development Program, the Executive Development Program and revamping of the existing training institutions must pay careful attention to the local context of capacity building at the strategic and operational levels.
- Building capacity for performance must be approached in tandem with creating a milieu to enhance performance and the incentive-performance link completed by factoring-in accountability into the equation. This highlights the needs for institutionalizing transparent managerial audit within public sector institutions at various levels. Careful attention should also be paid to developing appropriate instruments for assessing performance. Currently, the Annual Confidential Report is the chief instrument for assessing the performance of public officials in Pakistan; however it is widely perceived that it is not an effective instrument for promoting accountability and is also reportedly used as a means of exploitation.
- Civil service reforms to reorient institutional culture: civil service reforms should not just be about incentives for performance, about reforming a line for service or about compensation of bureaucrats. The reform process must focus on governance in its broader context and enhancing efficiency in the delivery of public services in a conducive institutional culture – a culture geared in the outcomes-efficiency context rather than being focused on short term gains. Therefore, in addition personnel management reforms which go beyond personnel action and set standards for performance and build mechanisms for their assessment and rewards there is a need to pay attention to transparent regulation and minimizing vested interests, political benefaction and interference in decisions, particularly in relation to recruitment, transfers and disciplinary actions as these are perceived as an impediment to efficiency within the system, in addition to being a demoralizing factor within the public sector.
- From civil service to public service reforms: the current focus on ‘civil servants’ within the context of ‘service reforms’ is understandable given that it is seen as an instrument for mainstreaming second generation macro-economic reforms. However if this is to translate into improved social services delivery, other cadre and ex-cadre categories of public servants must be brought within its ambit. One of the challenges posed to service delivery in the area of health and education relates to human resource – low numbers for certain categories, migration of skilled workers, misdistribution of workforce, staff absenteeism, dual job holding, lack of motivation to perform and the proverbial brain drain are manifestations of the lack of economic opportunities and incentives often complicated by other factors. These must be at the heart of a strategic reform process rather than ad hoc measures.
- Devolution vis-à-vis Decentralization: Civil service reforms to improve governance must also have an added context given that social service delivery is now devolved to 100 districts governments who have little experience of such responsibility in the past. This underscores the need for the reform efforts to pay close attention to two processes. In the first place, granting district autonomy and authority should proceed on a sliding scale with capacity as a due consideration. In the second place, it is important to build appropriate safeguards against several issues which have been brought to attention during the initial years of implementation of the Local Government Ordinance of 2002. For example, Provincial Governments still retain influence over establishment decisions and have considerable de facto control over recruitments, career management, transfers and termination. It has also been shown that
political and administrative ‘decentralization’ has also paradoxically created ‘centralization’ of some functions within the district itself as the DCO now has centralized control over all the staffing decisions vis-à-vis EDOs. In addition discrepancies in reporting relationships are also worthy of note in the context of the need to address them.
Many reforms measures are presently on their way to being structured and implemented in many sectors – of these the Police reforms, Judicial reforms, and reforms introduced by the Public Procurement Regulatory Authority and the National Anti Corruption Strategy have been announced and there may be others, in the pipeline. A reform agenda in the health sector has also been tabled by the Pakistan’s Health Policy Forum. However it must be clearly understood that the success of all these reform measures and others that may be in the pipeline will depend not only on the manner in which they pay due attention to human resource solutions – within the civil service – but also within the broader context of human resources. The aforementioned five points have been articulated with a view to catalyze a long term vision in line with this approach.
The author is the Founder President of the NGO Heartfile and Pakistan’s Health Policy Think Tank. E mail: sania@heartfile.org/Forum and the author of the Gateway Paper. E mail: sania@heartfile.org
Avian Flu – the short and long term contexts
Published in The News International on March 05, 2006:
Given that diseases such as the Plague, SARS, HIV/AIDs and Avian Flu do not respect national boundaries, the news of Avian Flu in our immediate neighborhood, left a slim choice between treading the prevent-prepare-control options a week ago. However its detection on an NWFP farm yesterday, made choices much clearer. Ever since Avian Influenza (H7N3) hit Pakistan in 2003-04 and was subsequently curbed at source in the agriculture and health sector through implementation of animal and human health surveillance, disease control and mitigation measures, some level of gearing up for another outbreak had been witnessed. Evidenced by news and other forms of reporting, efforts included the establishment of surveillance laboratories equipped to diagnose bird flu; enhanced allocations for strengthening surveillance and emergency preparedness and clinical, serological, and virological surveillance in migratory birds from different parts of the country. It is hoped that these investments will pay off given the recent emergence of the virus in NWFP.
However, the situation specific to Avian Flu and the earlier experience relating to the health situation consequent to the October 8 earthquake raise several policy questions for medium- and long-term planning. These relate to striking a balance between the short and the long-term measures; the capacity within the system to respond to a health crisis; the level of preparedness of the health systems to deliver emergency services; and most importantly, the extent to which a credible cost-effective and equity-focused analysis supports investments in these within a long term context. Three overarching issues of concern have been flagged here particularly with regard to medium and long-term planning.
Strengthening health systems: the threat of the Avian Flu looming has once again highlighted the need for strengthening what is generally the ‘invisible’ in the social sector – institutional systems and capacity. Decades of focus on programme-based service delivery and an over-emphasis on infrastructure development have led to neglect at the health systems level. On-ground analyses indicate that the success of any health programme depends on the robustness of the health systems; indeed one of the markers of such systems’ strength is the degree of preparedness and responsiveness to public health emergencies. Indeed many of the measures necessary to address the current challenge—particularly at the health sector level—are embedded in systems-level solutions. For instance, bulk purchase of anti-virals for people and vaccines for birds links in with procurement mechanisms in the public sector; their inventory management and distribution from central base/s to the grass roots level is dependent on a friction-less Federal-Provincial-District service delivery interface; the missed opportunities to deliver them through private sector health care providers ties in the need to leverage on the private sector to deliver state-mandated-health-related public goods and the ultimate provision of these vaccines and medicines at the grass roots levels forms an integral part of the service delivery potential of basic health infrastructure. Furthermore, designating hospitals for the treatment of the infected and equipping them to treat and care for affected individuals links in with issues of efficiency and sustainability. Prompt dissemination of standard treatment guidelines and training health workers in such diseases ties-in the role of continuing medical education programmes – currently nonexistent in the country. Systems-level solutions also need to be placed in the right structural, fiscal, and regulatory parameters; for example, another Avian Flu imperative which involves identification of laboratories for testing human and animal blood samples highlights the need for establishing a legal system that mandates the notification of diseases and regulates laboratory practices.
Strengthening systems must also proceed in tandem and with careful attention to the state asserting a stronger normative role. In the present situation guidelines for prevention and control of human cases of Avian flu influenza disease have been established by the National Institute of Health in collaboration with international partners; these must be widely disseminated. In addition, the State’s normative role in this situation needs to be further augmented within the broader context of the prevention- and control-focused methodologies and instruments.
Health Disaster Preparedness: secondly crises – natural or manmade – are marked by increased level of death and suffering and put health systems through complex and unique emergencies. Health policies should, therefore, incorporate disaster planning within their realm with a focus on preparedness, response, and recovery fostering collective responsibility to act effectively and enabling the development of new mechanisms and systems for health governance in the wake of these considerations. A National Health Disaster Preparedness Plan developed within an overarching disaster management framework is therefore, a strategic imperative; this must pay careful attention to mapping human resources and infrastructure, inventorising demands and developing contingency plans.
Health’s inter-sectoral scope: thirdly, it is well established that much of the scope of the public health work is conventionally placed outside the medical care service and that factors which determine health status range much broader than those which are within the realm of the health sector. Environmental changes such as global warming and changing ecosystems may have implications for spread of disease and its control; mass damage by biological weaponry is a possible threat to civil infrastructure with serious public health implications; natural disasters raise public health issues of great significance; humanitarian crises as a result of conflict and acts of terrorism are known to impact health status of those affected and global pandemics such as the recent SARS and Avian flu epidemics have cut health across the global economy and allied sectors, taking health concerns to a completely different level.
It is therefore imperative that alternative policy approaches be developed for health within an inter-sectoral scope. This necessitates a redefinition of objectives and targets within the health sector in order to garner support from across the sectors. However, these need to be set within a more explicit policy framework in order to foster inter-sectoral action. Relevant ministries and organizations need to own this approach and participate in a manner, which is mutually supportive of common goals. Support for this should come from the highest ministerial level in each instance and should also reflect the support of the Cabinet. Within this context, Avian flu is a case in point which ties the role of many government departments and the private sector.
With the threat looming, it is understandable that policy objectives must focus on short term planning; as part of such efforts mobilizing the public as a key partner in beating the disease, measures to compensate poultry owners and encouraging them not to conceal a bird flu outbreak by providing specific incentives, and formulating a short-term incident management program with clear designation of roles and responsibilities and a command and control system to effectively minimize loss in the event of an outbreak are therefore justified. However, daunting as they may seem – these should not prevent institutionally sustainable action set within the long term perspective given that this would be critical to strengthening the systems’ ability to cope with such disastrous events in future.
The author is the founder and President of Heartfile and Pakistan’s Health Policy Forum. E mail sania@heartfile.org
Pakistan Medical and Dental Council – strategic imperatives
Published in The News International on February 08, 2006:
Recent controversies around the Pakistan Medical and Dental Council (PMDC), the efforts presently underway to break the resulting stalemate and more topically offered solutions now favoring a major overhaul highlight an opportunity to flag some fundamental questions about the role of this institution. Mandated with a normative and regulatory role within the ambit of the medical profession, PMDC is a statutory autonomous organization. The PMDC Ordinance of 1962 and the subsequent amendments introduced in 1967 and 73 provide a policy framework enabling it to set standards of medical education, register practitioners and accredit academic medical establishments. But is this all that needs to be within the PMDCs remit? Or should its role be broader given that this is the only body that regulates the medical profession? If considerations of protecting, promoting and maintaining the health and safety of the patients are brought to bear – as they should given that they are the cornerstones PMDC’s code of ethics – perhaps there is a need for revisiting its scope. These bring to the forefront many other issues such as assessment of performance and accountability, credentialing of doctors through peer review processes, continuing medical education as a prerequisite to maintaining a PMDC license, accreditation and quality assurance mechanisms for private health facility infrastructure and effective adjudication of complaints. Currently proposed health reforms make a strong case for creating appropriate institutional mechanisms for this purpose; for example, the recently released Gateway Paper of Pakistan’s Health Policy Forum, makes a case for the creation of a National Council for Health Care Quality, Peer Review Boards, and institutional mechanism for Continuing Medical Education to support the reforms it proposes. Within this context it needs to be determined whether PMDC can perform these roles or is there a need for configuring independent institutional mechanisms for this purpose and in the case of the latter what relationships will these have to the PMDC given the cross-cutting mandates.
Expanding the scope of regulation – within or outside of PMDCs domain and presumably through autonomous institutes – raises the question of who gives autonomous institutions a regulatory mandate. Who enforces it and makes them accountable and in what manner? Granting autonomy to a regulatory institution such as the PMDC is quite unlike granting autonomy to service delivery institutions such as hospitals where appropriate policy and operational framework and mainstreaming of the market mechanism can serve the debatable core purpose of making them efficient and sustainable. However that is not the case with an institution whose core functions are normative and regulatory. Regulation and standard setting are the functions of the State per se. This is even more critical in a medical education context, which is not – and cannot be – a private sector forte. However this does not imply that an institution to regulate the medical profession cannot be autonomous. A certain level of autonomy in terms of ensuring that the voice of all stakeholders is expressed in decision making and management may actually be necessary to ensure that regulation does not become coercive, that standard setting is reflective of an appropriate expression of all perspectives and that the enforcement of these standards and norms is being overseen by a participatory process. However autonomous institutions in the truest sense work most efficiently and transparently in institutional and societal cultures that have fully matured to the realties of self governance. In settings where there are gaps at this level, professionally led regulatory institutions should be configured in a public sector-professional partnership and must not be separated from State oversight, the limitations of the latter, notwithstanding.
Given these considerations, four areas of reforms are proposed within the PMDC and PMDC allied-regulation context:
The first area of reform relates to PMDC’s governance functions and operations. In this area, there is a need to clearly separate the governance functions of the Council and its functions which relate to case work and adjudication of complaints with appropriate safeguards – not just byelaws but also their implementing mechanisms – to ensure the upholding of evidence in decision making and protection against interference from vested interest groups. In this area of reform, the terms of engagement of this autonomous institution, the level of State oversight and its mechanisms and the accountability paradigms need to be articulated with clarity and due representation of stakeholders ensured. There is also the need to bring greater clarity in the means of conflict resolution. This links in with some overarching questions about the mandates of the Senate and Parliamentary Standing Committees on health and how these relate to the operational scope of health policy implementation within Pakistan.
The second area of reform relates to revisiting its existing mandate. Here the feasibility of introducing conditionalities for retaining the PMDC license should be assessed. This can either be through the introduction of revalidation – or demonstration by doctors that they meet the standards required for continued registration – or through incorporating a Continuing Medical Education program as a prerequisite for maintaining a PMDC license. Ideally it should be a combination of both. There is also the need to assess the feasibility of revising the examination procedures and creating a national examination board.
In the third place it is critical to mainstream its role in the evidence and the policy cycle. By virtue of its core role to register medical practitioners, PMDC holds the largest dynamic database of healthcare providers in the country. There is a need to synthesize this ‘information’ into ‘evidence’ for policy-level decision-making with respect to human resource quantitatively from the supply and demand perspective, qualitatively, and with respect to their effective deployment. PMDC owned-data can potentially yield evidence in several areas. These may be relevant to personnel management reforms which should ideally go beyond ‘personnel actions’; pragmatic human resource solutions for public sector doctors with relevance to dual job holding and coercive bans on private practice; dealing with quackery, the effect of privatization of medicine on the quality of education and an analysis of the demand for these institutions vis-à-vis self financing schemes for existing public medical institutions.
And in the fourth place, drawing an analogy with the UK’s General Medical Council and connecting with the overall context of PMDC’s ethical principles and standards which determine its responsibilities, a serious thought must be given to the scope and scale of PMDC role within the context of broader considerations relating to regulating the medical profession. If the purpose is to protect, promote maintain the health and safety of the public, then there is a need to expand the scope of regulation – within PMDCs ambit or outside of it – to encompass considerations of performance assessment, credentialing of doctors, continuing medical education, licensing and accreditation of service delivery facilities, quality assurance mechanisms and the monitoring of errors. These considerations underpin the viability of the reforms being introduced in the health sector – at the level of delivery of services through basic health care facilities or hospitals or the financing of health care. Whether the PMDC can be restructured for this role or whether other institutional mechanisms need to be configured must be the subject of strategic deliberations.
The author is the founder and president of the NGO Heartfile and Pakistan’s Health Policy Forum – a health sector think tank. E-Mail: sania@heartfile.org
Improving heart health in Europe.
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