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The healthcare universe

Published in The News International on December 13, 2014: Plunged in the corner of an orthopaedic ward in a hospital in Pakistan, ZU, a 19-year-old labourer struggles with pain and discomfort, his leg arched over a metal frame at 45 degrees. Two bricks hang from a cord tethered to a nail stuck deep in his lower thigh, preventing the fracture he sustained a week ago from misaligning. Every now and then he gazes at the door to see if his brother is back from the village with the money needed to fix his leg. The only goat they possessed had fetched half the amount needed to buy a surgically implantable nail, necessary to cement the bone. His brother had now gone back to the village to borrow the rest. He wonders if his fate will be the same as that of the man at the far end of the ward, who was taken back home in a similar situation after ten days in the hospital after his family was unable to buy the surgical implant needed to fix his fracture. ZU...

Brainstorming a better world

Published in The News International on November 19, 2014: For the last seven years, every November around 800 thought leaders from around the world convene in the United Arab Emirates for the World Economic Forum’s Summit on the Global Agenda. Knitted as a global knowledge network of around 80 Global Agenda Councils on a wide range of subjects, the event is widely recognised as the world’s largest brainstorming event. A handful of Pakistanis are also invited each year. Typically every year trends with regard to challenges and opportunities of the upcoming year come under discussion and are outlined in an accompanying report, the ‘Outlook on the Global Agenda’. This year, the Outlook Report released at the event outlined 10 ‘global trends’ or ‘key challenges’ facing the world over the next 12-18 months. These challenges were compiled and ranked using the Delphi method. The report ranked them in order of priority, but here I cluster them and reflect on their relevance to Pakistan. I will club the economic challenges, ‘deepening income inequality’ and ‘persistent jobless growth’ into one cluster. These topped the list...

Ministries: a review

Published in The News International on October 31, 2014: A special cabinet meeting has been scheduled for today (October 31) to conduct a performance review of all ministries, divisions and departments. In this context, I am offering some reflections from my tenure as federal minister in the interim government last year. These reflections relate to the systemic constraints, which in my opinion, stand in the way of effective governance and hence hamper the government’s performance. The frame of reference is government ministries and the issues highlighted are of a long-standing systemic nature. First, an objective assessment of performance is possible only when goals, time-bound outcome-based targets, and performance metrics have been pre-defined. None of these is the norm in ministries. Government functionaries usually do not have a clear sense of delivery with no clear terms of reference and measurable operational targets in the context of overall goals for a sector. Hence as a starting point, these need to be framed. My second observation relates to expectations regarding the government’s performance, which matters deeply since it determines the context in which all societal actors...

Privatisation imperatives

Published in The News International on August 07, 2014: Privatisation is subject to intensely polarised political discussions, which cloud important policy imperatives that need to be appreciated. Six points are being outlined in this respect. First, we must get the framing on privatisation right. Privatisation must not be viewed through the narrow lens of sale of state enterprise to bridge fiscal deficit. Privatisation is deeply linked to the fundamental question of the role of the state in the economy and is part of a broader economic liberalisation and deregulation agenda. It is one of the policy choices a government can espouse to make the private sector the engine of growth with the understanding that the role of the government is to provide an enabling policy, impartial oversight, and a level playing field for market entities. When a country such as Pakistan embarks on the broader deregulation path, it has to be prepared to overhaul its own institutional competencies within government. This is a long-term agenda. Far from political polarisation, political consensus is needed to go this route so that the course can...

Polio at the centre

Published in The News International on July 22, 2014: Sometimes the rationale of a policy decision becomes apparent long after the actual decision itself. The imperatives created by the polio travel conditionality will help us understand why it was critical to re-establish Pakistan’s Ministry of Health (officially named the Ministry of National Health Services, Regulations and Coordination (NHSRC) under Pakistan’s Rules of Business). Imagine the scenario had the WHO travel conditionality, involving polio vaccination for individuals travelling out of Pakistan, come into effect before the May 2013 decision to create the Ministry of Health. There would have been mayhem at the federal level, with confusion about responsibilities since federal mandates for health were fragmented in nine institutions during Oct 2011-May 2013, the former representing the time when the 18th Amendment came into effect. To give a background, Pakistan’s Ministry of Health was abolished in 2011 by the 18th Amendment, on the notion that there was no need for federal ministries related to subjects that had been devolved, and since health was one of the 17 subjects devolved, its ministry was abolished. What...

Health in the post-2015 agenda: three considerations in moving forward

Nishtar S. Health in the post-2015 agenda: three considerations in moving forward. Nishtar S. East Mediterr Health J. 2014 Mar 13;20(2):71-2. Accessible...

Can human resources for health in the context of non-communicable disease control be a lever for health system changes?

Nishtar S and Ralston J. Can human resources for health in the context of non-communicable disease control be a lever for health system changes? Bulletin of the World Health Organization. 2013 November; 91(11):895-896. doi: 10.2471/BLT.13.118711. Accessible...

Local imperatives

Published in The News International on November 07, 2013: The Supreme Court of Pakistan instructed the provincial authorities in April 2012 to hold local government elections “without delay”. The reason was simple. The provinces had long been delaying the legislative process and the holding of local government elections. As the order showed, the Supreme Court had enough of the excuses presented by provincial officials and ordered the Election Commission of Pakistan (ECP) to conduct elections, maintaining that this constitutional requirement needed to be met one way or another. Subsequent to this, however, an issue emerged as the dates for the polls were set according to the statements of provincial officials, who when pressed for a date of elections, provided random dates, disregarding the electoral schedule. By doing this, the provinces ignored the ECP’s warnings that the electoral schedule should be based on legal and operational timelines for the electoral process, which includes delimitation, registration of candidates, objections, campaign, finalization of the voters list etc. In the past, the ECP stated repeatedly that it needed certain time to conduct elections, but it never published...

The 3G test

Published in The News International on November 01, 2013: Earlier last month, the Supreme Court directed the government to put in place the necessary institutional arrangements at the Pakistan Telecommunication Authority, in particular hiring of the three members central to the governance of this regulatory body, so that the long awaited 3G spectrum and licence auction could be expedited. In compliance a number of steps were taken by the government. However, the premise of the public policy discourse on 3G centres on the notion that the auction will yield revenue in foreign exchange, badly needed to offset part of the budgetary deficit. 3G should not, however, be as just a revenue-raising option; it has potential for much broader impact through its correlation with economic growth and development. As opposed to 2G technology, 3G enables better data usage and video content viewing because of the increased speed of mobile internet, not previously available to mobile-phone users. This is not a ‘good-to-have’ luxury but has important implications for economic growth, human development, and governance. According to the World Economic Forum’s Global Information Technology Report 2013,...

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...