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

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

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/

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