November 30, 2010: There are a number of competing priorities for allocating development assistance in Pakistan, today. Fiscal space has been crowded out in the aftermath of the recent floods, an energy crisis, ongoing war and relentless insurgency. The enclosed comment underscores the salience of some windows of opportunity at the margins of these challenges, using deliberations and pronouncements at the recently held Pakistan Development Forum as a peg.

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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.


November 16, 2010: In a recent review of ‘Choked Pipes’ published in the Lancet, the reviewer uses corruption as a peg to outline the book’s attributes and alludes to the notion of ‘the mixed health systems syndrome’ described in the book as a persuasive idea. WHO Bulletin’s review published in its November issue states that the “book provides a timely spotlight on the investment needed to develop effective, transparent and pro-poor health systems” and that it has “something to offer for both the local and global audience”. Download the Lancet review | Read the Bulletin’s review

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.