‘People are the currency of progress’: how Pakistan is battling stunting

How cash transfers prevent lockdown tragedies

June 3rd, 2020 World Economic Forum-COVID-19 and the pursuit of financial inclusion in Pakistan

May 5th, 2020 World Economic Forum -COVID-19: Using cash payments to protect the poor in Pakistan

Logic behind the langar Published in The News International, October 15, 2019

The Langar Policy is one of several policies under the Ehsaas umbrella, in its Safety Net category. This policy is being implemented in the public-private partnership mode, as part of which private charities and trusts will be supported to operate langars (soup kitchens) at designated government land/premises.

The policy is predicated in the understanding that many welfare organizations in the country, already providing meals to the destitute at some scale, have capacity to upscale further significantly, if strategic support is provided by the government.

Pakistan scores very high in philanthropic giving. According to estimates, more than Rs300 billion is channelled to welfare, annually. However, up until now, the government and welfare organizations have been siloed. There has been no strategic approach to collaboration. Ehsaas aims to change that, so that the expertise and resources of reputed welfare organizations can amplify with government support.

With regard to langars, the question is: what sort of government support is needed? To this effect, three areas have been identified. The first is logistic support because currently welfare organizations often face severe resistance in setting up langars where needed most. This happens because of market dynamics and reluctance of local administration due to fear of encroachment on prime public lands. The second way in which the government can play its role is by setting safety and quality standards, and the third is by disseminating information widely.

It has therefore been decided to support selected reputable organizations that have a proven track record of providing meals at scale, and facilitate their access to government land/premises in a predicable manner. Areas where this can work best include bus stands, industrial areas, railway stations, and places where labourers tend to congregate. The langars established will be tagged in the Ehsaas App (to be launched soon). This will allow the government to create awareness about their locations, enabling millions of destitute to benefit daily. And this would be at zero cost to the government.

This is quite a departure from the standard government style of execution, where ministries want control of execution, paving the way for corruption and inefficiency.

Based on this policy approach, an agreement was signed with the Saylani Trust to open 112 langars across the country. The prototype one was opened in Islamabad; Thar will be the focus for the next set of langars. The Saylani Trust already provides over 70,000 meals a day and with government support this will be doubled. Under the agreement, the expectation is that the trust will provide healthy and nutritious meals, ensure quality of food, cleanliness in the premises; and that in each langar, hand-washing will be promoted, trans-fats will not be used in cooking, salt will be kept to a minimum, and nutrition guidelines adopted by Ehsaas will be followed.

The framework of the Ehsaas Langar Policy will also enable other reputed long-standing langar-running NGOs to partner with the government over time. We will refine the model based on implementation experience. If at any stage government funding is needed, budgetary approvals, and compliance with the Public Procurement Regulatory Authority rules will be ensured.

We have started with langars but the scope of the policy to engage the private sector in ‘welfare activities’ will later extend to other areas, guided by evidence – orphanages, protection homes, schools for the marginalized, shelters for the homeless, etc. We believe public-private synergy in a context of unprecedented giving in Pakistan can significantly scale up the work of welfare organizations, benefitting millions. Hence, an overarching Ehsaas public-private engagement policy is also under development.

Overall, the government is aware that one isolated action, policy or initiative isn’t the answer to tackling poverty, which is why the Ehsaas strategy has more than 134 mutually-reinforcing actions, designed to target different groups. Safety net initiatives are for the lowest rung – stipends for women; new policies for orphanages, disabled, shelter homes, and child protection; and Tahafuz to protect against catastrophic risks.

To help people graduate out of poverty, the policy windows include the National Poverty Graduation Initiative, financial inclusion strategy, and prize funds (first wave announced yesterday) for innovative solutions such as the new design of Thela, and garbage collecting rickshaw to create jobs are the bottom of the pyramid. Similarly, labour protection is another stream in Ehsaas, as is human capital development under which financial access to health and education are main instruments (Insaf card, need-based undergraduate scholarships, and education stipends).

As an integrated whole of government programme, Ehsaas is being executed step-by-step. Each intervention helps to reinforce the other, while we simultaneously also work on making programme improvements based on implementation insights.

To help with Ehsaas’ execution, a new ecosystem had to be built – a national survey (ongoing), digital payment system, new ministry, financing arrangements, IT systems, Delivery Unit, oversight committees, Ehsaas governance and integrity policy, and partnerships policy – a massive task in its own right.

As far as langars are concerned, we know the evidence is compelling in a context. We know that they lessen despair among the homeless. They restore dignity and self-reliance to those that will otherwise go hungry, and they contribute to grassroots activism and social cohesion with food security and nutrition aims. They also provide jobs to those involved in the operations.

The prime minister is personally committed to ensuring that no one goes to bed hungry in Pakistan – and the government will work hard to realize that vision.

The writer is the special assistant to the prime minister on poverty alleviation and social protection.

Twitter: @SaniaNishtar

The Ehsaas strategy Published in The News International, September 17, 2019

The Ehsaas Strategy has been released today (pass.gov.pk/) to solicit public input, prior to its finalization. The strategy elaborates on the prime minister’s vision of a welfare state.

This is the first time that a government document has gone to government officials and the public for review at the same time, introducing a culture of openness and transparency.

Ehsaas is unique for three reasons. One, with currently 134 policies and programme elements, Ehsaas is the most ambitious umbrella initiative the Pakistan government has ever undertaken aimed at social protection and poverty alleviation.

Two, it takes a multi-sectoral and multi-stakeholder approach, recognizing the importance of the private sector, civil society and multisectoral across-government collaboration.

Three, Ehsaas is embedded in a theory of change, reflected in four pillars: action against elite capture; safety nets; livelihoods and jobs; and human capital formation with a focus on lagging areas.

Safety nets are the short-term priority within Ehsaas in view of the current fiscal austerity measures. To expand safety nets, the social protection budget has been increased and to promote integrity, the Ehsaas Governance and Integrity Policy has been prioritized. Work on the new national socioeconomic database has been fast-tracked to enable precise targeting.

The soon-to-be-launched ‘One-window Ehsaas’ will address fragmentation. To promote policy coherence and coordination, the Poverty Alleviation and Social Safety Division ‘the Ehsaas Ministry’, was established, and the previously fragmented federal social protection agencies were placed under its administrative control. BISP’s digital payment system is being revamped after a nine-year delay.

Under the new BISP programme, ‘Kifalat’, the 5.7 million BISP beneficiaries, which were previously receiving ‘cash only’ will now have access to bank accounts, mobile phones, financial literacy, digital hubs, labelled cash transfers, and graduation opportunities. The National Poverty Graduation initiative – comprising interest-free loans, asset transfers, and vocational training – and projected to impact 16.28 million individuals over four years has already been launched.

‘Tahafuz’ – Pakistan’s first shock-oriented precision safety net, will be launched by December. Ehsaas also includes welfare policies for the differently-abled, the homeless, orphans, street children, seasonal migrants, transgender, victims of child and bonded labour, daily wage workers, substance abusers, workers abroad, informal labourers, and domestic workers.

Under Ehsaas, undergraduate scholarships are on the anvil in collaboration with the HEC. A new health and nutrition conditional cash transfer programme to address stunting is in the final stages of planning, and education conditional cash transfers are being upscaled for five million children.

Beyond social protection, Ehsaas recognizes that the determinants of poverty and inequality are complex – as are the measures to address it.

Global lessons show that massive poverty reduction is the result of overall robust and sustained economic growth, when combined with economic freedoms and the will of governments to counter organized vested interest and elite capture. In Pakistan, elite capture is the root cause of poverty and is evident in water management, crop choices, land use priorities, labour laws, the taxation system, cartelization trends and nepotism patterns.

The government’s vision is driving change at various levels to address this. In its framework, Ehsaas has included objectives under Pillar I ‘Address Elite Capture’ to assist that overarching mission.

For too long, the levers of our system have been in the hands of a small group of elites. As an attempt to break that system, a constitutional amendment to move Article 38(d) from the ‘Principles of Policy’ section into the ‘Fundamental Rights’ section reflects the philosophical change within Ehsaas, while on a practical basis, Ehsaas stipulates pro-poor goals, and conflict-of-interest norms for every ministry; polices to protect resources for pro-poor initiatives; and guidelines for parliamentarians on use of development expenditure.

Ehsaas Pillar III is predicated on the understanding that human capital development is a significant contributor to the wealth of a nation in this digital age. Therefore, to catalyze action, provincial Ehsaas plans are being developed.

Ehsaas aims to create safety nets for at least ten million families, livelihood opportunities for 3.8 million people, and financial access to healthcare for ten million families. Scholarships/education incentives for five million students (50 percent girls); financial and digital inclusion for seven million individuals (90 percent women) and an enabling environment for poverty reduction by promoting mutli-sectoral partnerships and innovations. These goals will be expanded based on new partnerships. A new policy and framework of commitments will allow the private sector and the civil society to make commitments.

The strategy document outlines the government’s vision, or Ehsaas’ bedrock; the principles which drive it; the context which has shaped it; the Theory of Change, which underpins its conceptualization; and the four pillars under which its goals, policies, and programmes are organized. The strategy also outlines the manner in which 21st century approaches can be used to build a welfare state – data and technology for precision safety nets; financial and digital inclusion; human capital formation; women’s economic empowerment; value chain building for agriculture and crafts; Solutions Innovation Challenges to develop solutions for poverty; measures to address malnutrition, and multi-sectoral and multi-stakeholder approaches for solutions at scale.

Ehsaas’ premise is grounded in the importance of strengthening institutions, transparency and good governance. We realize that the limited capacity of public institutions, and governance challenges often impedes their ability to deliver. Therefore, Ehsaas is also planned with the ambition to fight through all such challenges – in that respect, implementation of the Ehsaas Governance and Integrity Policy assumes great importance.

To be fully successful, Ehsaas will need to effectively use all government levers to drive change in one direction. I strongly believe it is possible to achieve that with a constructive approach to collaboration.

The writer is the special assistant to the PM on poverty alleviation and social safety.

Twitter: @SaniaNishtar

More provinces? Published in The News International, May 1, 2018

Calls to create more provinces are once again resonating across Pakistan as the elections draws closer. Beyond the election rhetoric, the objective of creating more provinces in the country should be carefully deliberated to ensure that this exercise strengthens the federation and democracy rather than stirring ethno-lingual factionism, which is detrimental to good governance.

As a starting point, it must be appreciated that a province/state – in other words a sub-national and, indeed, a federating unit – has a specific status and purpose in a federation. A federation (as opposed to a unitary or confederal style of political state) is characterised by a union of partially self-governing sub-national units under a central/federal government where power-sharing between the federal and the provincial governments is constitutionally entrenched. Pakistan is one of the 27 federations in the world where the power-sharing formula between its federal and provincial governments is stipulated in its constitution. Power-sharing was altered in favour of the provinces by the 18th Amendment and the 7th National Finance Commission Award less than a decade ago.

Federations can either be as large as Russia; Brazil; and the US or as small as Saint Kitts, Nevis and Micronesia. Regardless of their size, the federating units in all federations need to have an incentive to stay in a common economic union. Contrary to popular belief, the creation of more provinces on an ethno-lingual basis could end up strengthening the federation. Allowing people to own their identity helps them become part of the mainstream, and feel less dominated and, therefore, not alienated – attributes that are vital to the viability of a federating country.

There is also a structural justification for increasing the number of provinces in our country. Pakistan has a unique situation as one of its provinces (Punjab) is larger than the sum of all others combined in terms of population size. There are difficulties inherent to the functioning of a federation when this is the case. However, we need to be mindful of the objective here. While increasing the number of provinces could potentially strengthen a multi-lingual/multi-ethnic federation, if apolitically and effectively managed, it cannot ensure improvement in the performance of governments until it is coupled with appropriate governance reforms and systemic safeguards against corruption.

To enhance the government’s performance and its capacity to govern, we must institutionalise checks and balances, and rule-based control on how the government functions and root out arbitrariness; politicisation; and bureaucratic political allegiances.

A culture of evidence-based decision-making; accountability; transparency; respect for merit; integrity; ethical conduct; and conflict of interest safeguards are critical to any meaningful attempt aimed at improving the performance of the government. The creation of more provinces will do little for the government’s effectiveness and its ability to deliver if these attributes aren’t well-institutionalised.

The creation of more provinces should also be viewed in the context of the federal-provincial relationships in the post-18th Amendment context. Eight years on, there are still countless unresolved matters; elements of mistrust; and tenuous relationships. This was also evidenced recently in the impasse during the meeting of the Council of Common Interests in relation to the federal-provincial differences over development budgets. With such unresolved matters and the lack of evidence to inform the next steps, culling out more provinces is unlikely to be effective.

In terms of the way forward, it would be important to plan incrementally. First, there is need to draw on evidence to ascertain the impact of the 18th Amendment on provincial governance and federal-provincial interface-functioning. Problems highlighted through this exercise need to be resolved as a matter of priority. A plan for a prototype model of ideal provincial and district functioning can then be drawn up in an evidence-based manner. It is critical for such a model to be grounded in a rationalised approach to recurrent fiscal implications, with cost-effectiveness as its yardstick and capacity-building inherent to its framework. This would also be an opportunity to usher in a digital transformation of the government with appropriate incentives to reshape behaviour.

Such a plan can be implemented with multi-partisan and civil society oversight. A roadmap can be developed to launch a pilot and adapt learnings. Once it is known to be effective, it can be applied on a broader scale.

This process will, however, require careful consensus-building at the national level. The implications of more provinces on administrative and fiscal matters need to be thought through carefully. Other matters, such as provincial representation in the Senate, will need political consensus. But we need to be mindful that all this will be futile if not paralleled with tangible governance reform. Increasing the number of provinces is justifiable. But we need to be mindful of the objective. Rather than a means of politicking and whipping up ethno-lingual zeal as a short-term election objective, the focus should be on using this reform as a means of strengthening the federation and improving governance. In order to achieve this, careful planning; execution; and the right motivation are needed.

Email: sania@heartfile.org

www.sanianishtar.info

Twitter: @Sanianishtar

The e-voting challenge Published in The News International, April 13, 2018

Discussions on e-voting have re-emerged as the election draws closer and the National Database and Registration Authority (Nadra) gears up to present its plans about the three-tiered Internet Voting System for overseas Pakistanis, this week. Since I came across this subject in my capacity as a federal minister in the 2013 caretaker government, I am sharing a few insights for the planning currently underway.

E-voting for overseas Pakistanis was a subject of much discussion during the initial days of the 2013 caretaker government. The Supreme Court had issued a directive in response to a petition about the establishment of an e-voting system for overseas Pakistanis and had directed that this be expedited. Within this context, the Election Commission of Pakistan (ECP) convened a meeting of government functionaries for the process to be facilitated, which is how I and other ministers were invited to the table.

After the first meeting it became clear (at least to me) that it would be practically impossible to turn around the task in eight weeks due to time limitations. Although Nadra had developed a customised application and had demonstrated its use during presentations at the ECP, several steps were needed to be completed before the software could actually be deployed. Perhaps the most important was that it needed testing in real life situations overseas, along with quality and integrity audits, which are time consuming.

The procurement process of the hardware, on which the application was to run, was yet to be initialised. To ensure the system functions in Pakistan’s missions abroad, human resource was needed to be hired and trained, and their visas and travel arranged. The Ministry of Foreign Affairs had been pursuing permissions from the nine countries that the Supreme Court wanted this system to be functioning in. There were huge implications for Pakistan’s missions abroad in terms of physical requirements, awareness creation and compliance with local procedures. Eight weeks was nowhere near enough time to develop a foolproof system. A half-baked attempt could have been catastrophic. I volunteered to appear before the Supreme Court to explain the situation.

I narrate this story because as per the Supreme Court’s decision, e-voting for overseas Pakistanis is to be implemented this time round. I would like to flag two points in this regard. First, there are differences between the 2013 and 2018 Pakistani e-voting pilot systems. In 2013, Electronic Voting Machines (EVMs) were developed for deployment in Pakistan’s missions abroad but the project could not come to fruition. The EVMs were later used in the NA-4 by-elections in October 2017, and important lessons were learnt about their limitations. However, the system is not going to be used for the upcoming 2018 elections.

In contrast, the 2018 envisaged e-voting system allows voting from remote locations using internet, rather than at polling stations, and is being developed for overseas Pakistanis. Although each option has its own inherent challenges, one key lesson is that every new system needs adequate time and planning for conceptualisation, deployment, integrity checks, piloting and ploughing back lessons to refine the model. Other supporting factors – procedural, administrative and legislative – need to be taken into account when planning, as technology is only one cog in the process chain.

When I stepped down from my role as federal minister in 2013, I had reiterated in my Handover Papers the need for the next government to take this matter up in a timely manner and examine implications carefully. I am not privy to details as to how the matter was dealt with over the last five years, but if a demonstration is being given now, the process must be in its pre-pilot stages.

Second, there are important lessons to be learnt from the e-voting experience of Estonia. Estonia became the first country in the world to offer internet voting nationally – in local elections in 2005 and later for parliamentary elections in 2007, which is when 30 percent Estonians voted through the internet. Lessons from the Estonian example are critically important since Pakistan’s infrastructure of digital identities is somewhat similar to the Estonian model.

In 2016, an independent assessment of the procedural components of the Estonian Internet Voting System was conducted by the Cyber Studies programme of the University of Oxford. The evaluation highlighted the importance of the Estonian experience in conducting electronic elections for the last eleven years. However, while praising the system, the evaluation highlighted the unique circumstances under which Estonia has been successful and questioned the ability of the systems’ procedural controls against sophisticated cyber-attacks. The threat of cyber security is so real and pressing that in Brazil, the Brazilian Supreme Electoral Court has gone so far as organising ‘hacking competitions’ to create additional confidence in the technology. Recognising security challenges, several European countries including the UK, Germany, Netherlands and Norway cancelled e-voting systems or have decided against its large-scale use.

On balance, internet voting is feasible, which if effectively deployed, could improve accessibility for voters, especially those that are overseas and others for whom access is an issue, such as the disabled. It could also potentially save costs and time. However, in practice, the most important thing is that there needs to be a high-level of confidence in the system. Success depends on the expertise and experience of the team. There must be adequate time for the system – and not just the technology – to develop and undergo rigorous integrity checks.

Designing effective operational and procedural controls and safeguards against the risk of tampering is fundamental for the success of the programme. Estonia is grappling with this issue after two decades of having commenced on this journey. Pakistan’s institutions mandated with e-voting should ascertain where they stand in this process, and the implications a fallout would have on the credibility of the election. More broadly, they should assess how this relates to the provisions of ‘secrecy of ballot’ and ‘anonymity of voters’, which are enshrined in our constitution. As democracies around the world struggle to deal with hackers, fake news and twitter bots, would now be an optimal time to use limited resources on rolling out a lightly tested internet voting system?

Email: sania@heartfile.org

www.sanianishtar.info

Twitter: @Sanianishtar

Corrupting health Published in The News International, April 7, 2018

Over half the world’s population is denied essential health services. This means that scores of communities cannot get the medicines they need, have no hospital to go to, are not being immunised and receive no advice about family planning. This is a sobering reminder on World Health Day.

To make matters worse, ill health often serves as the harbinger of poverty around the globe – with more than 800 million people spending over 10 percent of the money they have on healthcare. On a recent trip to Africa, I heard a harrowing story of a hospital where women and their newborn babies are routinely held hostage for months until families settle their bills.

Across South Asia, and here in Pakistan, we all hear stories of children being pulled out of school, cattle sold, and valuables pawned in desperate attempts to keep death at the door and food on the table. The financial hardships and unforgiving compromises households go through in order to take care of a sick relative tend to worsen when it is the breadwinner who is unwell.

There is a growing consensus that the solution to these intertwined health and economic challenges is universal health coverage (UHC), the theme of World Health Day 2018. Countries are investing in UHC to ensure that everyone has access to quality health services without having to suffer financial hardship. Far from the one-size-fits-all model, different countries use different policies to achieve UHC, depending on the unique natures of their health system, disease burden, budget and political backdrop.

With non-communicable diseases like cancer, diabetes and heart diseases on the rise, the need for UHC is becoming more pressing by the day. These diseases, once contracted, tend to stay with people for the rest of their lives, requiring the kind of sustained care and treatment that only UHC can provide.

Fortunately, the momentum around UHC is growing by the day. The World Bank has suggested that the health of a country might affect its ability to borrow, further elevating the healthcare system’s rising profile with finance ministers – typically more influential than their colleagues in health – and even heads of state. At a major forum organised by the Japanese government on the issue, Japan’s prime minister recently pledged $2.9 billion to promote UHC globally.

But even with the new packages of funding, the central barrier facing UHC is lack of money, due to strained public coffers, corruption and waste. In addition to being one of the world’s biggest sectors, healthcare is also one of the most corrupt and inefficient sector. Across the world, corrupt and collusive practices –ranging from petty theft to organised crime rackets – are well-institutionalised. The world spends nearly $7 trillion – roughly 10 percent of the global GDP – on healthcare. But $455 billion of this money is estimated to have been lost to misuse or fraud. So, at the same time that healthcare is bankrupting many of the poorest people in the world, it is increasing the bank balances of some of the richest. Corruption in the healthcare sector undermines efforts to achieve UHC by eroding financial protection efforts whilst simultaneously increasing barriers to healthcare.

It must be appreciated that UHC, anti-corruption and action against tax evasion have shared agendas. It is increasingly recognised that tax evasion does not just enable money laundering but also shrinks tax revenues, which are essential for UHC to work. It is promising that the Sustainable Development Goals include a target to “significantly reduce illicit financial flows”.

Fighting corruption requires action at many levels. Treasuries, finance ministries and dedicated anti-corruption agencies alike, must focus on prevention, detection and enforcement. Good governance needs to be better incentivised. Making financial systems more transparent will be critical to curbing health corruption. And it is not just government and business that have roles to play here; civil society, the media and patients must also demand accountability. Data mining and blockchain offer some new opportunities in detecting wrongdoing and should be fully explored for the health sector.

Demanding that more money is raised and that it is better protected and used, securing the funding needed for UHC is not a task for one government department alone, nor is UHC an undertaking that can fit into just one term of office.

Underpinning care for people throughout their lives, UHC is an inherently intergenerational programme that requires sustainable level of funding in the long run – in the fullest sense of the term. Countries will need to deeply engrain this commitment to UHC within the national psyche, even as governments change hands and more immediate pressing crises come to the fore.

Email: sania@heartfile.org

www.sanianishtar.info

Twitter: @Sanianishtar

The future of government Published in The News International, March 17, 2018

Governments in countries such as Pakistan – with exploding and rapidly urbanising populations – face increasing challenges to deliver ‘good government’. In the context of scarce resources and declining trust, it is increasingly becoming difficult to ensure the key government mandates: delivery of law and order, justice, services to bridge inequalities, market competitiveness, and effective and even regulation.

Fortunately, technology provides an unprecedented opportunity to provide solutions even for low-resource settings. These opportunities have been tapped by the private sector, and have created islands of progress in the public system. The critical question is: will governments be able to harness them to bring about quantum change in their performance?

Even in Pakistan, when you seek services online, fast food chains and online taxis deliver on the objective of trackability, efficiency, transparency, and accountability. The same technological capabilities that underpin these service delivery mechanisms could, if well managed and strategically deployed, support the development of innovative public-sector digital ecosystems that are transparent, accountable and responsive.

The potential of Pakistan’s existing public-sector IT systems should be the starting point to explore potential. The National Database and Registration Authority (Nadra) provides solutions for identification. This infrastructure of digital identities is the foundation on which to plan the digital transformation of government services. The Republic of Estonia, the most advanced e-society in the world, is an example of what is possible. Estonia recently received the Government Leadership Award for moving public services into a fully digital mode and making 95 percent of government e-services available through mobile apps. Pakistan has the infrastructure to enable that. The country’s experience with e-filing of tax returns, initial experience of e-filing of FIRs, and land revenue automation as well as other similar initiatives – most notably those initiated by a provincial IT Board – can be the starting point for upscaling.

The Federal Bureau of Statistics’ Geographic Information System can be the foundation for location-enabled services. For example, it can be used to identify schools that are off population centres and crime sites in relation to where police stations sit. This can also enhance the government’s analytical ability and effectiveness.

Triangulation of big data from various sources and data exchange between the state’s information systems can yield significant gains, ranging from predicting diseases to improved tax collection.

Countries that are rapidly progressing have all opted for online single windows for business registration, and Pakistan must do likewise. Mobile payments systems, which are now fully developed, can be tapped for wholesale government-to-citizen payments – for example, pensions, where we know ghost payments are a problem.

Easily deployable technology applications such as video surveillance can monitor Basic Health Units and Schools, just as fast food chains monitor their branches and GPS location technologies can be used to checkmate absenteeism in public-service delivery. Sector specialists can outline a menu of practical applications of commonplace ICT solutions that can drive change in virtually every sector.

The government’s internal functioning also needs to benefit from technology. Tools within government such as e-office (system of moving files electronically) have existed over a decade. Its trackability features can improve transparency, rule-based control and efficiency and time-stamping could ingrain accountability. ERPs are used by most private-sector organisations; clearly, the country’s largest employer, the Government of Pakistan, could benefit through its use.

Technology helps fight corruption and entrenched rent-seeking, which is part of the reason why there are obstacles to upscaling these simple and often cost-effective solutions in our setting. But many countries are relying on technology precisely for this reason, and some have gone as far as to use it to promote integrity in political practices. The use of a mobile app to track campaign finances by the California Fair Political Practices Commission is a case in point.

But technology by itself is not the solution; its deployment in transparent ‘processes’, which hedge against abuse, is key. Hence, large-scale technology deployment works best in environments where the appetite to address corruption and intent to base decisions on evidence exists. Failing this, decision-makers find avenues to insulate process, which vest powers of discretion from getting automated.

There is also the need for a change in mindset. Here we see drones taking pictures at weddings and political rallies. But countries such as Rwanda are using drones to deliver blood products to haemorrhaging women in far-flung areas, and for humanitarian relief.

To usher in a digital transformation of government, technology must be deployed in new systems with appropriate incentives to reshape behaviours. New governance and regulatory models are needed to set standards, formulate policy and address concerns around privacy and security which could hinder adoption. Partnerships are key to draw on the expertise of various sectors.

Governments need to invest in new capacities (both human and technological), in infrastructure (such as e-service kiosks in rural locations) and in digital literacy. An assessment of digital maturity and the technologies and platforms needed, is a requirement, after which a roadmap can be developed to launch pilots, adapt learnings, then scale broadly. Provincial governments should engage in collaborative work, share lessons and prepare initiatives for nationwide scale up. The workforce needs to be realigned with this digital age, which is where the Higher Education Commission can play a key role.

We are starting from a long way back, but we must also prepare to tap the potential of breakthrough technologies, such as blockchain, artificial intelligence and robotics, which have significant potential to reshape governments’ potential further.

To ensure that Pakistan takes full advantage of new technologies to tackle some of our biggest challenges, an overarching digital government strategy is needed to accelerate rollout. Engaging citizens in helping shape this strategy will be critical to its overall implementation. As Pakistan, and indeed the world, goes through transformational changes, uptake in innovative technology is one of the government’s best assets to stay ahead of the curve.

Email: sania@heartfile.org

www.sanianishtar.info

Twitter: @Sanianishtar

Nurses: our silent heroes Published in The News International, March 8, 2018

Over the last year, as the global movement for women’s equality and gender parity gained momentum, we saw a sea change around the world. Women have demanded their right to work safely, be paid fairly and live without fear of harassment and harm. This movement has been a long time coming. But it is only the beginning.

As women (and men) continue to advocate for change from #MeToo to #TimesUp and beyond, we must make sure that our vision includes uplifting women from all backgrounds across the world.

The fundamental building block of a girl’s life, whether in Botswana or Baltimore, is her health. Before a young girl in Pakistan can run a company or a country, she needs an equal chance at living a healthy life. Most girls never get that opportunity. That is why investing in women’s health around the world from birth to adolescence is both the right thing to do and comes with a huge economic dividend.

Fighting for women’s health equality isn’t an abstract slogan; it is the keystone of women’s equality. It also provides the most immediate opportunity to ‘press for progress’ — this year’s theme of International Women’s Day.

The Millennium Development Goals did help accelerate progress. However, there is still a lot more work to do. Every day, 830 mothers die in childbirth. Many of them literally bleed out at the roadside, unable to get to a hospital to get the services they need.

Unfortunately, women are dying from largely preventable or treatable complications. Adolescent girls are at a heightened risk of complications at birth. And yet, an estimated 16 million girls give birth every year. Many countries have failed to realise the commitments enshrined in the UN Convention on the Rights of Child, which prohibits marriage under the age of 18. Woefully, at least 214 million women are still unable to access family planning services that would allow them to control when they have children.

Ending child marriage and ensuring girls are educated has multiple benefits. Educated girls grow up with the skills and experience needed to make their own choices; get better jobs; have children later; and tend to space their pregnancies to suit their needs. They can lift themselves and their families out of poverty.

Women’s health often focuses only on their reproductive capacity. However, the biggest killers of men and women are now noncommunicable diseases (NCDs), such as cancer, diabetes as well as lung and heart disease. Two-thirds of deaths among women are caused by NCDs, violence and injuries. And yet, the myth that these killer diseases are mainly the domain of men persists despite evidence that suggests otherwise.

Overweight and obesity is the gateway disorder driving much of the NCD crisis. The near-double rates for women in their twenties and thirties are worrying since it is not just maternal undernutrition but also over-nutrition that undermines human capital development — the strongest indicator of the success of nations in this digital age. In fact, so significant is its interplay that the borrowing costs of countries are likely to be affected by their human capital rankings by 2025.

Maternal malnutrition has far-reaching consequences for human capital development. Women who are themselves stunted in childhood tend to have stunted offspring, creating an intergenerational cycle of poverty and reduced human capital. Malnutrition in the womb also increases the risk of adult obesity and NCDs. Therefore, many developing countries have a double malnutrition burden, with obesity coexisting alongside under-nutrition and stunting.

Gender differences in obesity and under-nutrition rates reflect the underlying gender inequality and socio-economic factors. Where female empowerment and workforce participation isn’t the norm, women are more likely to be obese. Gender inequality in society swings the pendulum of the nutritional status towards both excess female obesity and under-nutrition among women and children while greater gender equality resets the balance and favours human capital.

Gender inequality is not only a barrier for prosperity and economic growth, but also has a strong correlation with poor social outcomes. Addressing gender inequality is, therefore, critical for human capital development. Supporting and improving the education of girls; enabling women to access credit and land; and promoting the political rights of women along with their participation in economic life are potentially vital underlying interventions to address the human capital development challenge.

Over the last year, the global women’s movement has successfully taken on entrenched patriarchal and hierarchical systems to address these challenges. On this International Women’s Day, it is time to drive a women’s health revolution that saves lives and improves social and economic outcomes.

Helen Clark is the former prime minister of New Zealand and former administrator of UNDP. Dr Sania Nishtar is co-chair of a High-Level Global Commission on NCDs, the founder of Heartfile and a former federal minister.

Nurses: our silent heroes Published in The News International, March 01, 2018

While they are often in the background, nurses are at the heart of every national health system. They do everything, whether it involves caring for patients, administering lifesaving treatments in emergency situations, supervising health workers or ensuring that the correct information is passed between doctors and patients. Nurses are, in effect, the silent heroes of the healthcare system.

This week, a new global campaign, titled ‘Nursing Now’, was kicked off to celebrate the critical role that nurses play in delivering health services across the world. The campaign also seeks to ensure that recognition for nurses translates into leadership positions at all levels of the health decision-making system. ‘Nursing Now’ will run until the end of 2020, which is when nurses will be celebrated worldwide to commemorate the 200th anniversary of Florence Nightingale’s birth.

‘Nursing Now’ is an evidence based-campaign. It was conceptualised following a global review of nursing by the UK’s All-Party Parliamentary Group on Global Health, which concluded simply by reiterating that universal health coverage – the central pillar of the health-related Sustainable Development Goal 3 – cannot be achieved without developing the nursing sector across the globe.

It is no secret that the world’s health system is struggling to cope with old and new problems. Infectious killers like HIV, TB and malaria are still a major challenge in low- and middle-income countries. In addition, growing antibiotic resistance and the risk of a pandemic are presenting a tranche of new challenges that are threatening the progress made over the last few decades.

At the same time, every country in the world has seen a rise in noncommunicable diseases (NCD) that are largely driven by the global epidemic of obesity and other lifestyle-related risks. Cancer, diabetes as well as lung and heart diseases are now the leading killers of a vast segment of the population. This has presented new challenges along with climate change, new patterns of migration and the risk of new disease pandemics. Suitable reforms within the national health systems are needed to address the changing global burden of disease.

One of the fundamental principles for delivering quality health services for all is a solid workforce of well-trained and adequately supported community health workers, nurses and doctors. In order to ensure that the health workforce can tackle the new health challenges of the 21st century, it is estimated that nine million more nurses and midwives are needed by 2030. In Pakistan, there is a critical need to address this gap, where the current doctor-nurse ratio has been 2.5:1 for some time as opposed to the recommended 1:4.

This gap in the number of nurses isn’t the only issue that needs to be addressed. More often than not, nurses are undervalued and, therefore, unable to fulfil their desired potential. There are a variety of reasons for this. Since nursing is mainly a female-oriented profession, nurses are disadvantaged by traditional patriarchal structures. Despite their holistic understanding of the health system, nurses are often shut out of the health decision-making system owing to strict hierarchies and ingrained ideas about the role of nurses.

Investing in nurses in Pakistan and across the world will enhance their potential and improve their working conditions. Training and leadership skills can deliver the triple impact of improving healthcare, empowering women and strengthening local economies. As a trusted part of their communities, nurses are a key element of the process that can help us overcome today’s health challenges.

If they are properly deployed, valued and included in decision-making processes, nurses can play a critical role in promoting good health; identifying and preventing disease outbreaks; and providing care at the community level. When nurses are trained well and given greater scope to expand their roles, they deliver impressive results for patients. Maximising this potential will be vital to achieve the UN- approved goal for universal health coverage.

We are committed to ensuring that we don’t just recognise nurses but are also able to develop pathways of growth for them. We are keen on breaking the patriarchal and hierarchal systems that keep nurses from becoming key elements of the health decision-making system at all levels. One of us, as co-chair of UK’s All-Party Parliamentary Group on Global Health, is leading the global drive to mainstream the role of nursing in health systems. The other, as the co-chair of WHO’s Independent Global High-Level Commission on Noncommunicable Diseases, supported the idea that a nurse was included in the commission. Nurses are on the frontlines of the battle to tackle NCDs and drawing upon their skills and experience is critical as it determines how the commission will develop and give action to new policy recommendations to turn the tide against fatal diseases.

Nurses have been on the periphery of decision-making in the health system for too long. As the world’s health changes, we must ensure that nurses are leading the charge in how we restructure health systems to tackle the challenges of the 21st century.

Lord Nigel Crisp co-chairs UK’s All-Party Parliamentary Group on Global Health.

Dr Sania Nishtar is the co-chair of a High-Level Global Commission on NCDs.