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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...

Pakistan’s deadly cocktail of substandard drugs

Pakistan's deadly cocktail of substandard drugs. The Lancet - 5 March 2012. DOI: 10.1016/S0140-6736(12)60277-3 Download Attached file #...

The drug debacle – Part I

Published in The News International on March 05, 2012: In 1937, more than a hundred people died in the United States as a result of using a drug formulated with a toxic solvent in what came to be known as the Elixir Sulfanilamide Tragedy. The incident was a wakeup call for the then US administration and led President Roosevelt to sign the Food, Drug and Cosmetic Drug Act into Law in 1938. The new law significantly increased federal regulatory authority over drugs and mandated the creation of the US Food and Drug Regulatory Authority (FDA). The FDA was created as a federal entity in the United States’ federal system, even though health was a state subject. Since then, the FDA has become a global reference institution and has prevented the occurrence of similar events. For example, in the late 1950s and early 1960s, when the Thalidomide horror struck in the rest of the world with more than 10,000 children in 46 countries born with limb deformities, as a result of their mothers using the drug Thalidomide, for morning sickness, the US was...

Pakistan and polio

Published in The News International on November 23, 2011: At the recent meeting of heads of Commonwealth states, Australia put polio squarely on the table with a 54 million dollar promise. This adds to the existing pledges towards the disease eradication goal, which has collectively received more resources than any other global health intervention, to date. There is one problem though and Pakistan is in the dock once more—this time as a living threat to the global goal of eradicating a disease for the second time from the face of this planet. The weight of the allegations is mighty. After 23 years of commencing the World Health Organization-led Global Polio Eradication initiative, billions of dollars in investment, mobilization of 20 million health workers and a population wide intervention in 125 countries, vaccinating more than 2 billion children, there are only four countries in the world which continue to harbor the disease. Pakistan is the only country where cases have steadily increased since 2008. The country’s progress, as labeled by the Independent Monitoring Board of the Global Polio Eradication Initiative, now lags...

Devolving health (Part II)

Published in The News International on September 03, 2011: Pakistan’s Ministry of Health was abolished on the 30th of June and a number of federal health responsibilities were placed under the jurisdiction of seven other government ministries/divisions. The dynamics of this change and the questions emerging as a result thereof have been discussed in these columns on July 23. This comment presents an option for the way forward with regard to entrusting national/federal health responsibilities to appropriate institutions at the federal level. Most of these functions are linked to each other. Information, a key responsibility, has to be consolidated across streams, that in turn informs high level decisions related to national roles, in particular disease security, trade in health, federal fiscalism, external resource mobilization, each with a deep bearing on provincial and district level service delivery, health financing, human resource management and health governance. Failure to retain national responsibilities and ensure their institutional linkages can have serious consequences. I have attempted to illustrate these by building five hypothetical scenarios. Scenario 1, 2013: Pakistan becomes the last remaining reservoir of poliovirus transmission in the...

Some misunderstood attributes

Published in The News International on August 16, 2011: In this rapidly changing globalized and inter-connected world, some recent events are compelling us to redefine existing norms and practices. Burgeoning tensions earlier in the Middle East highlighted the need to accord higher priority to mainstreaming democracy. Recent riots in Europe underscore the salience of social reform whereas the global financial crisis necessitates greater attention to transparency within global and domestic financial and regulatory systems. Pakistan is undergoing unprecedented transformations in this changing world. The country has opted for deep-rooted reform of its federating system through the 18th Constitutional Amendment at a time when many conventional as well as human security challenges lurk on the economic, social, and demographic fronts. The local government system is in flux, calls for new provinces are echoing loud, and remodeling of governing arrangements has become the basis of settling political disputes. Can these broader brush “reform” measures enable Pakistan to address its core systemic distortions, its key determinants of past failures and the challenges we are faced with today? Do reform attempts grounded in constitutional amendments and...

Devolving health – a way forward (Part I)

Published in The News International on July 23, 2011: On June 28, a notification of the Government of Pakistan articulated a plan for completing the process of devolving many subjects, including health, as part of the final stages of implementing the 18th Constitutional Amendment. As a consequence, the Ministry of Health (MoH) was abolished and Pakistan became the first federal country in the world without any central coordination for health. Whilst making this change, those at the decision making helm, however, rightly understood that there are “national” roles in health, which cannot be devolved and retained them at the “federal” level. This notwithstanding, the Commission, charged with the responsibility of implementing the amendment opted for a “cut-and-chop” formula for the MoH, housing various institutions and functions either under the command of seven other divisions—Inter-provincial coordination, Capital Administration and Development, Cabinet, Planning, Economic Affairs, States and Frontiers Affairs, and Federal Bureau of Statistics (FBS)—or merging them with other institutions. Within this context, I will try to be as constructive as possible in this comment in offering a way forward. Let me begin by reiterating...

Drug regulation and beyond

Published in The News International on June 25, 2011: The establishment of a drug regulatory authority is once again on the policy agenda, this time round as part of implementation of the 18th Amendment-relevant devolution of health. In principle this is a step in the right direction. Whilst the service delivery functions of health need to be devolved, it is equally important to recognize that national health functions need to be served federally, as is the case in most federations around the world. In a recent analysis  (http://www.heartfile.org/pdf/HEALTH_18AM_FINAL.pdf) four subjects have been described as falling within the purview of health’s ‘national roles’—information, regulation, international commitments, and several elements of policy. The policy rationale for retaining drug regulation at the national/federal level is robust in keeping with internationally prevailing trends. In addition, independent regulatory institutions are now a prerequisite in the post-WTO scenario since none of the flexibilities under the TRIPS agreement in terms of the rights of member countries can be availed unless there is an independent regulatory authority. Work in this direction is not starting de novo. The draft “Ordinance...

Solutions from within

Published in The News International on May 28, 2011: The events of May 2nd and 21st have left the nation embarrassed and demoralized. The challenges arising as a result thereof may compound Pakistan’s existing problems. Many find it difficult to search for beacons of hope within the myriad of problems at a time like this. Within this context, this comment is an attempt to explore if there is reason for hope, and if so, what is it, that needs to transpire to turn the tide in a positive direction. Whilst trying to frame an answer to this question, I am reminded of another question I was once asked at an international meeting: “how would you describe the Pakistani society?” Struggling to portray a positive image of my country, I was fortunately able to quickly recall that a “society” is much broader than the “state” and that whilst the state may be predatory and beholden to capture at various levels, these attributes don’t necessarily describe societal characteristics. A society in any nation state comprises a number of human and institutional actors and relationships and...

Pakistan prepares to abolish Ministry of Health.

Nishtar S, Mehboob AB. Pakistan prepares to abolish Ministry of Health. The Lancet May 4,...