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: firstname.lastname@example.org