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Financial crisis, social unrest and reform

Published in The News International on January 05, 2009:  The December 22, 2008 issue of Newsweek featured an article on the downside of Chinese state reform. Entitled 'Why China is too scared to spend', the article drew attention to the weaknesses created in the Chinese health system with the advent of market reforms in the 1980's, which did away with the communes that funded the Chinese system of work-unit based welfare. The consequent negative impact on the Chinese social sector hit healthcare the worst, as bare foot doctors in villages and affordable hospitals in towns were replaced by privatized state enterprise. Currently, a majority of the population spends out-of-pocket to seek healthcare and as rightly pointed out in the article 'a serious illness can wipe out a family's savings'—a pattern labeled as catastrophic spending. The word 'catastrophic' in the present context denotes an economically dire outcome for a family. This pattern of spending in health comes to the spotlight in view of the recent financial crisis because of its implications for spending patterns, as Chinese families, unprotected in terms of their...

Global crises—imperatives for a just social order

Published in The News International on December 14, 2008: There is an apprehension within the development circles that the economic impact emanating from the crisis in international commodity markets and the affects of the global financial downturn coupled with constrained fiscal space in the country as a result of a number of factors inherent to Pakistan's domestic situation is likely to hit development budgetary allocations hard, over the coming months. Such a situation is indeed plausible. While the lack of full integration of Pakistan's financial markets with international markets, to some extent precludes the adverse impact getting imported into Pakistan as it has in the more integrated markets of East Asia, notwithstanding the synergistic effect of other factors will mean that the government will have fewer options to raise additional resources to support the social sector budget. Pakistan will, from now on have to comply with the stipulations of the International Monetary Fund; these ingrain fiscal discipline and should not be used as an excuse to limit social sector expenditures. On the contrary these times require strengthening of interventions that...

Scaling up research and learning for health systems: time to act.

Evans T, Nishtar S, Atun R, Etienne C. Scaling up research and learning for health systems: time to act. Lancet 2008;372(9649):1529-31. Download Attached file #...

A new war – against polio

Published in The News International on October 23, 2008: Pakistan's security situation and the war on terror has become a top priority for the government. While the need to prioritize issues is understandable, attention to some other matters of the state on a war footing is also warranted. In many ways, the case of polio eradication is analogous to the war on terror given the international context within which it is being waged and the gains at stake. Since 1998, a Global Program on Polio Eradication spearheaded by WHO and involving many other agencies aimed at eradicating a disease from this planet for the second time in the world's history since Small Pox eradication in 1979, has been ongoing. This initiative, involving 125 countries, more than 20 million health workers and vaccination of over 2 billion children worldwide has been able to achieve the polio eradication milestone in all except four countries of the world. The premise is simple: immunization is a right of every child, vaccination is the most cost effective health intervention and a few drops of polio...

NAB and related governance issues

Published in The News International on September 30, 2008: The government has decided to repeal the National Accountability Ordinance 1999, and has drafted a bill to legislate for an alternative accountability mechanism; with the promulgation of these statutes, the National Accountability Bureau (NAB), Pakistan's apex agency mandated in an anti-corruption role will be replaced by an alternative accountability body. The draft bill is not in the public domain and cannot be commented upon and the shortcomings of the earlier Ordinance have not been publicly debated. Notwithstanding, an opinion is offered as this clearly, can be an opportunity to address current weaknesses in the country's anti corruption institutional mechanisms and legal system. Within this context, the objective of this opinion is threefold: first to contextualize NAB's niche in the broader remit of institutional arrangements that are of relevance of anti corruption reform. Secondly, to comment on the need for other statutes that need to be promulgated in tandem with an accountability law. Thirdly and most importantly, to draw attention to other broader measures and sectoral approaches in public sector reform, which...

Democracy and governance – upstream determinants

Published in The News International on September 08, 2008: With the conclusion of presidential elections, the power configuration within the state has been defined. 'Majority rule' or 'a few ruling with the consent of many', described by the Greeks centuries ago, as a characteristic feature of democracy has been established within Pakistan and constitutional stipulations as articulated in Part III of the Constitution with reference to its Chapters on the President and Majlis-e-Shoora (Parliament) have been adhered to. At this stage, let us be reminded that while democracy, as understood conventionally is a necessary condition for a good government, it is certainly not a sufficient condition. This comment is intended to objectively draw attention to other characteristics that need to be woven into the equation in order to enable democratically elected governments to successfully navigate the ship of the state. Democracy is not just about 'majority rule'; it is an amalgamation of many attributes. First, it is a set of institutional arrangements or constitutional devices; by this measure, Pakistan has achieved a democratic milestone. However, there are other institutional democratic...

Independence Day – an ode to governance

Published in The News International on August 17, 2008: 14th of August is as august as a day can get, both for Pakistanis who have witnessed the perils of partition and experienced the anguish of being in a subservient role as well as those of us born after independence; the latter can be attributed largely to 'temporal depth' – the characteristic understanding in nations of the past forming part of the present – and our collective consciousness, both of which we hope, will cascade to the next generation. Most of us would like to believe that the 'nation', as a territorial community and 'patriotism', as a commitment to the well being of our country, constitute an important aspect of our lives. However, other than periods of intense enthusiasm witnessed during the wars and the more recent sentiments of solidarity exhibited in the aftermath of the devastating October 2005 earthquake, we are often not clearly mindful of what truly constitutes the nation's well being. Allow me to illustrate that point further. As government entities at various levels, businesses, NGOs, civil society,...

National trade policy 2008-09 – the trade-health interface

Published in The News International on August 09, 2008: It is conventional for the commercial sector to assess and comment on the potential impact of a trade policy as was evidenced by the plethora of commentaries on the media subsequent to the enunciation of Pakistan's National Trade Policy 2008/09, on the eve of July 18, 2008. The social sector seldom considers it within its remit to scrutinize possible impact of the course of action adopted on social outcomes nor does it create awareness about the need for trade policies to include elements relevant to their scope. However, the contemporary understanding of trade, which scopes beyond merchandise to also include services and human resources, is changing that notion and creates an imperative for the national trade policy to broaden its scope. The case of health is illustrated to demonstrate why and how this is so. The World Trade Organization's General Agreement on Trade and Services and majority of regional trade agreements allow countries to undertake commitments in trade and investments in health services if they so desire, in line with their...

Governance Empirics

Published in The News International on August 03, 2008:  Between the government and their critics, opinions relating to the government's hundred-day performance are at the extreme ends of a spectrum. Unfortunately as a nation, we are not in the habit of being impartial in performance evaluation. The objective of this opinion is not to ascertain whether objectives were met or whether they were reflective of national priorities in the first place, but to emphasize that it is only through impartial empirics and the use of validated instruments and indicators, as opposed to self determined benchmarks, that meaningful inferences relevant to the performance of governance can be drawn. Of the various available tools, this opinion chooses the World Bank's composite indicators, which measure governance in six domains; the World Bank has recently used this tool for its global report entitled Governance Matters – a cross country comparison assessing 'broad notions of governance'; a detailed in-country exercise to build further on the data would be timely and useful. There can be many areas for a detailed Pakistan-specific assessment under each indicator;...

Health Policy – chinks in the armor

Published in The News International on July 14, 2008:  In the midst of all the overarching challenges the country faces, sectoral policy and strategy appears to be relegated to the background; the latter cannot be mainstreamed in any case without sound institutional governance, which is also a determinant of the currently prevailing broader issues. Let's take the example of health where the government's initiative to formulate a new national health policy could be the starting point for the much needed reform within the health sector. Certain sound technical choices can be made and if evidenced-based strategies are adopted to synergize a technically robust and administratively feasible agenda, a viable basis for restructuring the health system can be made. However, the issue is not at the level of 'technical choices' but with the manner in which institutions govern policy change; there are two critical impediments at this level; first, the ability of state institutions to build on evidence and secondly, their ability to ensure that policy reforms introduced, are taken to fruition over the long term. A historial review demonstrates that health...

Romancing health insurance

Published in The News International on June 28, 2008: With all the four provincial budgets for the fiscal year 2008/09 tabled, the annual provincial development programs for the next year have been unveiled. Provincial development budgets range from 22.12-41.13% of the total outlays with Punjab spending the highest and Balochistan the lowest. 1.84-12.15% of the total provincial development budgets have been allocated for health with Sindh allocating the highest in relative terms. On the whole, provincial health allocations suffer from limitations that are somewhat similar to those described for the federal health budget in the author's editorial in The NEWS on June, 20. However, a consistent reference to health insurance as a potential means of financing health in budget speeches has prompted this opinion in an attempt to bring clarity to the potential therein. First of all, it is important to recognize that there are broadly two means of financing health – public and private; public sources, which include tax and pooling (social health insurance and exemptions are the two ways of pooling) are more equitable in protection against health...