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Health and research in Pakistan – Authors’ reply

Bhutta ZA, Nishtar S. Health and research in Pakistan - Authors' reply. Lancet 2013; 382(9900):1246 Accessible...

Butchers galore

Published in The News International on August 23, 2013: Lying in a surgical unit of the Khyber Teaching Hospital in Peshawar is an elderly woman with half her abdominal wall practically eaten away by infection – the outcome of a surgery carried out in a district hospital, which was mismanaged in the first place and became infected later. She has several gaping openings, through which the insides of her abdomen and muscular tissue can be seen. For those who have the stomach for such sights, I have posted the picture on my website (www.heartfile.org). Surgeons in Peshawar are patiently treating her but give a guarded prognosis. Such patients, bearing the insignia of surgical malpractices, are usual at Pakistan’s teaching hospitals all over the country. Most suffer at the hands of quacks, imposter doctors and others that are bona fide in ‘degree’ but not in ‘practice’. Although there is no dearth of these ‘doctors’ in cities, it is the rural areas that serve as havens for them. This unfortunate woman is an illustration of policy failings on the part of successive governments...

Policy is not a menu

Published in The News International on July 10, 2013: As I stepped down from my role as a caretaker federal minister last month I attempted to introduce two precedents through my Handover Papers – voluntary submission to accountability and a formal process of handing over government. In one of these, I reflected on some of the challenges that have constrained the government's ability to govern. Twenty-one caveats have been outlined, referring to the government's core business, its institutions and instruments of governance, the modalities of policymaking, human resource considerations and key governance attributes. In this article I elaborate on the caveats related to the executive's public policymaking role. The frame of reference here is domestic policy. The term public policy has been interpreted widely; beyond a set of norms embodied in the constitution, legislative acts, judicial decisions, and formally declared government policy documents, public policy can also be framed in any other policy instrument, whether regulatory or economic in nature. Policy formulation is the government's core 'business'. If government is the key to the fortune of the 180 million people in this country,...

Ministers and accountability

Published in The News International on June 21, 2013: Accountability and transparency are deeply misunderstood in our country. For decades, the two have been regarded as being synonymous with politically motivated anti-corruption efforts. Nothing could be further away from the truth. Transparency opens a window into the world of government operations. Accountability, on the other hand, provides a measure of how government is performing and shows the nature and underlying motivations for decisions. Developing transparency and accountability systems builds confidence in government and presents avenues for engagement with businesses, citizens and the civil society for achieving inclusive and sustainable growth. Transparency of decision-making is also a way of regulating conflict of interest, one of the key ethical questions in governance. I am a staunch believer in the role of transparency and accountability as central threads in governance and democracy. Hence, when I was sworn in as federal minister in the interim cabinet, I decided to voluntarily submit myself for accountability at the end of my term. But how do you do that in a system where there are virtually no mechanisms in...

Mega misnomers

Published in The News International on February 06, 2013: Pakistan’s national and human security challenges have never been so pervasive. A war along the northern borders and relentless insurgency threatens the writ of the state, pitting law-enforcement agencies against people. Vested-interest groups exploit and deepen existing polarisation on ethnic, sectarian, political and religious fronts, resulting in carnage. These problems have created unprecedented pressures on an economy already plagued by serious structural problems, crippling power shortages and poor governance. Human security and state security have become inextricably linked. Our unique pattern of polarisation has become a threat to state security. Compounding all these are sequential natural disasters, which have put the lives of millions at risk. The spiralling population too is becoming an overload, and with high levels of poverty and unemployment our youth has become vulnerable to exploitation. Pakistan today stands very low in most international rankings. In a recent report comparing Asian countries, Pakistan’s health and education indicators have hit rock-bottom. Our ranking in the UNDP’s Human Development Index is 145 out of 187 countries. We are off-track in meeting the MDGs...

Great trepidations

Published in The News International on December 29, 2012: The brutal assassination of nine grass-roots level health workers in Pakistan, who were involved in a door-to-door immunisation campaign in an attempt to secure children from the crippling disease of polio, adds an unprecedentedly grave dimension to the ongoing carnage in Pakistan. Pakistan’s parliament was quick in passing a unanimous resolution and there was widespread condemnation of the killings from all factions of the society – and rightly so. These incidents have deep-seated implications for the global drive to eliminate an infectious disease for a second time from the planet. Additionally, they illustrate the nature of polarisation, mistrust and extremism that has crept into the Pakistani society, posing challenges on many fronts – beyond public health. This tragedy comes at a time when the Independent Monitoring Board of the Global Polio Eradication Initiative had, in its November 2012 report, issued a positive note about Pakistan with regard to its efforts to curb polio. Pakistan’s polio programme reduced cases by more than 60 percent since last year (from 154 to 64), indicating that things could turn around...

DRA: a case for hope

Published in The News International on December 05, 2012: The bill creating a much-needed federal drug regulatory authority – Drug Regulatory Authority of Pakistan – was enacted into law recently. The World Trade Organisation (WTO) agreements have made it binding on all countries to have independent drug regulatory authorities, without which key flexibilities permissible under the Doha Declaration on Public Health cannot be availed. On the domestic front, the 18 Amendment to the constitution omitted the entry “Drugs and medicines” along with the Concurrent Legislative List, which had earlier given provinces the mistaken notion that drug regulation could be a subnational prerogative, leading to an unnecessary year-long federal-provincial turf battle over drug regulation. It was only after 125 lives were lost in the Isotab-related drug deaths in Lahore that the matter of drug regulation veered in the right direction. Now that the authority has been created, it is time to take stock of the safeguards that need to be built to make it effective. First, independent regulation needs robust and transparent governance or it will fall prey to vested interest groups. It is...

How to achieve international action on falsified and substandard medicines

Attaran A, Barry D, Basheer S, Bate R, Benton D, Chauvin J, Garrett L, Kickbusch I, Kohler JC, Midha K, Newton PN, Nishtar S, Orhii P, McKee M. How to achieve international action on falsified and substandard medicines. BMJ. 2012 Nov 13;345:e7381. doi:...

The new wings of development

Published in The News International on November 05, 2012: The concept of development, through which governments view social policy in environments where capitalism is the mode of social organisation, may be up for a major rethink, globally. This year, policy signals at agenda-setting global convening and major publications seem to be heralding new directions. But in each of these, the onus of responsibility is seen to be swinging more squarely towards domestic policy. Three points are being outlined to draw attention to the potential levers of change and possible insights for Pakistan. First, there is a palpable emphasis on “investment” rather than “aid” as a strategy for development, and recognition, that development happens through “jobs”, rather than through “growth” alone. In fact, the World Development Report, 2013, has featured jobs, boldly in its monosyllable title and has opened with the statement “development happens through jobs”. Indeed, evidence confirms that one of the strongest determinants of achieving many development outcomes is per-capita income. Ideally, governments should aim to create the conditions that catalyse investments – macroeconomic stability, rule of law, enabling legislation, facilitative regulation,...

Freedom under a shadow

Published in The News International on August 15, 2012: Great trepidations shadow Independence Day. With the country’s increasing isolation in the arena of international politics, poor state governance, and a polarised society, Pakistan survives today primarily on the resilience of its people. This is a time to reflect on where we stand in the broader global context and appreciate the nature of the imperative. Foremost, it should be recognised that Pakistan today exists in a world where interconnectedness and interdependence is the new global order, creating opportunities but also risks. An increasingly multi-polar world with rise of the emerging market economies-two of them in our immediate neighbourhood. We now have a world where the G20 matters as much as the G8. Similarly, we also have a context where decision-making structures of the post-World War II global governance system must now accommodate new international players. Pakistan is clearly not one of them. The country’s “geostrategic significance” should not be confused with the importance of the emerging countries, which, despite many weaknesses, have strong prospects for sustainable growth and robust institutions. On the other hand,...

The drug debacle – Part II

Published in The News International on March 06, 2012: Currently, there is just one drug quality testing laboratory in each province but most are either inoperative or lack infrastructure, equipment, or qualified competent and experienced staff. It is critical that the government invests as well as attracts investments in this area.   An appropriately structured arrangement can have public-private resonance, offering a commercially viable investment opportunity. A sustainable system can also be developed which serves a public goal by ensuring quality of medicines.   This is also a time for a deeper policy review of the problem of substandard medicines. Pakistan today ‘boasts’ of 709 pharmaceutical units but none of them are FDA-certified. A large number of manufacturing units have been set up on shoe-string budgets and are quality deficient from the outset.   Many experts are of the opinion that the deterioration in the pharmaceutical manufacturing standards, amongst other things, is the result of the former MoH’s irrational policy – also currently in effect – of linking licensing of products to having one’s own manufacturing facility. This forces every new supplier entering the market to set...

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