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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

Political party manifestos – a sectoral insight

Published in The News International on February 16, 2008:

The pre-election political party debates relating to their positions on various sectoral processes of the state on national television, has prompted many of us to review party manifestos with the view to exploring strengths and weaknesses in an attempt to determine the deciding edge. Although the process may be indecisive, it leads one to acknowledge the fact that writing a manifesto must not be an easy task as bringing clarity and coherence to a range of party positions is a task that demands both strategic capacity and vision within party ranks. Given this, the effort to come up with manifestos, notwithstanding their weaknesses, is a step in a positive direction and should form the foundation to build further based on inputs from technical contributions. One of the areas that need substantial honing in each of the manifestos is health and it is with the intent of offering policy inputs into the process that a few non-partisan observations are articulated herewith.

Health has been addressed as a key area in the manifestos of most parties; however, the online version of Awami National Party’s manifesto does not have a section on health. While reviewing each of the health sections of respective manifestos, one expects a reflection of several aspects – the model of health services and financing a party envisages structuring in order to address the current issues in the health sector, their position with respect to their commitment to fund allocation and the priority areas for fund utilization.

First, on the issue of the health services model, both PPP and PML-Q come up with the concept of ‘National Health Services’ in order to deliver on the health for all premise. It must be appreciated however, that a National Health Service, modeled on the Bhore Commission Report of 1946 has existed in Pakistan since the country’s inception in 1947. Based on the report’s recommendations a three tiered network of health facilities – which on paper is one of the most extensive in the developing countries – has been structured; the problem is that the model doesn’t function well. The determinants of this failure are embedded in a complex interplay of insufficient government funding to sustain its own health infrastructure and an environment, which enables the private sector to operate in the delivery of health, largely unregulated. When health providers have better incentives to work in the private sector the issue of dual job holding and absenteeism arises and specialists use their public job leverage to boost private practices; lack of transparency in governance causes misappropriation of talent, collusion in contracting and procurement and therefore pilferages from the system and all these factors act together to lower the quality of public services.

Countries with welfare systems where health care provision is the responsibility of the state, such as in Scandinavia and the Middle East have a very high percentage of their budgets allocated for health to begin with and their regulatory environments do not let the private sector predominate in health care delivery. Even in resource constrained settings where the level of contributions may not be as high such as in Cuba and Iran but where the private sector is not allowed to operate, a difference in the quality of services is apparent evidenced by their health indicators, which compare much more favorably.

The solution to these issues is not in prioritizing investments in hospitals as has been stated by most manifestos, but by reconfiguring the mode of service delivery. The solution is also not in being coercive with the private sector as they are here to stay but in harnessing their strength through frameworks for public-private partnerships in tandem with innovative market harnessing regulatory methods that foster quality and can enable the government to leverage the market to deliver health as a public good. This requires major institutional overhaul of the Ministry of Health and departments of health who need to enhance their capacity in normative and regulatory tasks. Unfortunately none of the party manifestos come clearly and coherently on the issue of a consolidated position on such a health reform, which is badly needed; only one manifesto has referred to the potential of public-private partnerships in passing.

Secondly, service delivery reform has a major bearing on how health is financed and vice versa; in this domain, of all the manifestos, Tehreek-e-Insaaf and MQM have referred to alternative financing mechanisms. However both need revisiting. MQM’s health insurance scheme for all citizens could be an issue given that more than 40% of the citizens work in the non-formally employed sector where lack of a mechanism to make compulsory contributions at source from salaries would render a universal health insurance scheme unviable. What would have been more pragmatic is to refer to a health insurance scheme for those in the formally employed health sector and social protection and cash transfers for services in order to offset the risk to the poor in the non-formally employed sector.

Thirdly, is the issue of fund allocation. Of all the manifestos only MQM has alluded to a commitment to increase the health budget from 0.6% to 4% of the GDP. Although this is a welcome commitment there are many milestones to be achieved before this can be a pragmatic reality given the limited capacity to expend and utilize funds in the social sector and limitations to target funds effectively. Therefore what is needed in tandem is a clear articulation of how reform at a governance level is envisaged to enhance capacity in these areas. Another imperative of fund utilization is to ensure that the opportunities to plug leakages from the system are maximized. This has a bearing on anti-corruption and transparency promoting measures. Most manifestos allude to anti-corruption, however the emphasis is on institutional measures and developing mitigates against using institutions as tools for political exploitation. What is needed now as part of post-manifesto strategic planning exercises is for clarity and consensus on measures in the administrative and operational domain to implement ethical and administrative codes of conduct that strengthen the incentives-performance-accountability paradigm.

In the fourth place, a part manifesto has to be reviewed with respect to its position on priorities for resource allocations in health. It is here that the focus on creating more state supported infrastructure and hospitals and MCH and trauma centers in ‘every district’ as mentioned by MQM, PML-Q, PML-N and PPP in different parts of their manifestos is worrisome. There is no dearth of public sector hospitals in the country; however most of these are unsustainable and inefficient and have management issues; therefore before considering further investments in infrastructure, structural reform of the existing institutions is needed. Again only one manifesto refers to the word ‘hospital autonomy’ in passing, which is one of the many measures that can be used to make existing hospitals sustainable.

On a similar note, priority commitments to invest in high-cost technologically-advanced equipment as referred to by one manifesto must be reconsidered as that would take the focus away from prevention of diseases, which is more cost effective. Of all the manifestos, PML-N and Tehreek-e-Insaf allude to prevention in some detail. However, it may have been best to frame priorities for prevention based on an objective assessment of need and potential for preventability. According to the Federal Bureau of Statistics, 56% of the deaths are now due to non-communicable diseases (heart diseases, cancer, and diabetes); none of the manifestos refer to the need for developing a prevention and control program to address this challenge. One manifesto refers to supporting tertiary care for these diseases in the private sector; clearly this has to be low on the list of priorities. Within the prevention domain and as a cross cutting social sector theme, many manifestos have alluded to safe water but with the same focus of setting up filtration plants as is presently being done. Safe water needs cannot be met with filtration plants alone and have to be locally determined in rural and urban areas. For example, in rural areas needs are predominantly shortage-related and can be amenable to locally-developed solutions such as infrastructure investments on making storage tanks, hand pumps and check dams, as the case may be, based on geographic considerations. In the urban areas, for example, a number of measures such as changing corroded pipes and addressing sewerage leakages into broken pipes and issues of land use may be the solution. Party manifestos have not placed due emphasis on these measures.

Lastly, two of the manifestos focus on telemedicine and one of them focuses on promoting telemedicine in ‘every district’; here caution needs to be exercised as promoting telemedicine without attention to issues relevant to the availability of communication infrastructure in remote areas where telemedicine is actually needed and more importantly, provider buy-in from the standpoint of incentives can lead to investments without corresponding outcomes. On the other hand, there are other uses of technology such as in health information systems, reducing costs and medical errors, e learning, continuing medical education and tracking of records to promote transparency within the system, which are more effective and must receive due attention.

There is a reason for using health as an insight into manifestos. Health and education should be one of the foremost priorities of the state as they are a true sign of a country’s development. Health issues feature prominently in all pre-poll political debates particularly in the developed world as is evidenced by the current political process in the United States; given the size of the challenge in our country, and the complexities of the envisaged reform, one would hope that parties set their priorities and directions right.

In these tumultuous times, the winning party(ies) in the election will have many issues to grapple with and planning within the social sector may not seem as urgent as many other political, security and macroeconomic issues. Notwithstanding, certain strategic directions must be determined; the substance within these directions will not only determine how serious the new government is in addressing problems in the social sector, but will also indicate their sincerity to the cause of improving lives of the poor – a catchphrase they use to win elections.

The author is the founder president of a health think tank, Heartfile. Email 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

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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