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Health and the 18th Amendment

Published in The News International on April 02, 2011: The Implementation Commission of the 18th Constitutional Amendment, in its recent session, has taken the final decision to devolve the Ministry of Education. The next round of deliberations will decide the modalities of devolving another set of ministries, including the Ministry of Health (MoH). My comment in these columns on December 25, 2010—the Vanishing Ministry—outlined several institutional considerations that need attention whilst making decisions in this regard. One of these refers to the question of the national role in health and related institutional arrangements. Lessons from other countries are instructive in this regard. There are at least 25 countries with federating structures where health is a fully devolved subject. All have federal institutions—a ministry, state department, directorates or equivalent institutions—taking responsibility for “national mandates” in health. For this and many other reasons, there is a strong case arguing against MoH’s abolition. Contrary to what is being planned, there is need for stepping up capacity within the MoH, as there are many ominous indications of its constrained capacity—the case of polio and H1NI are illustrative...

Doctors’ movement

Published in The News International on March 19, 2011: Young doctors in the largest province of the country are on strike for the 17th day running. With revolutionary fervor from the lawyers’ movement and the Middle Eastern revolutions shaping our societal political culture, it seems that the movement is having a snowball effect. An increasing number of young doctors, groups and associations are galvanizing support for the Young Doctors Association, the apex body, which lent impetus to this movement. Their cause is becoming a rallying cry for drawing attention to a number of systemic constraints in relation to human resource issues as they impact young doctors. Their demands are legitimate—pay raise, pay protection, increase in health budget, and implementation of a service structure and regularization of doctors on contract. However, the determinants of the problem and possible policy approaches are complex and multi-dimensional. This comment aims to highlight some of the policy insights and imperatives which interplay in this complex space. First, these demands have arisen in a fiscal year where there has been a massive development budgetary squeeze, after the floods of...

The Challenges of Scaling up.

Nishtar S. The Challenges of Scaling up. Lancet...

Non-communicable diseases: evidence-policy disconnect

Published in The News International on February 12, 2011: World Bank’s report ‘Tackling Non-communicable Diseases in South Asia’ made headlines in Pakistan, yesterday. This is an important subject and its significance should be appreciated by policymakers. The report highlights the magnitude of burden attributable to a set of diseases, widely prevalent throughout all countries of south Asia—diseases which are linked by common risk factors, are largely preventable through cost effective interventions, but which have remained outside of traditional public health planning. It is now well established that certain heart diseases, stroke, diabetes, and some cancers and chronic lung conditions are the biggest global killers. In Pakistan they are the leading preventable cause of death, disease and disability in the adult population. These diseases have enormous social and economic costs with a serious negative impact on human and economic development. They impede progress toward the UN Millennium Development Goals, particularly toward poverty reduction and lead families into the medical-poverty trap. Yet, the prevention and control of Non-communicable diseases (NCDs) is outside of mainstream public health planning in Pakistan. It is neither part of...

Operation polio

Published in The News International on January 29, 2011: The government and opposition factions appear to be converging on a ten-point Agenda focused on eliminating some of the currently prevailing governance distortions in Pakistan. Articulated as a set of “Demands” by one particular opposition party, the points have been endorsed by others and have been admirably embraced by the incumbent federal government. The ten-points, per se, are non-controversial and there appears to be a broad consensus that action towards them will contribute positively in an environment where mistrust and malfunction are now deeply ingrained. This comment is aimed at explaining that whilst these points are significant stepping stones, and are important in their own right, they are nevertheless inadequate for addressing deeply rooted systemic issues, which can only be amenable to reform at a more fundamental level. Three points are being highlighted to elaborate this further. Six of the ten demands center on eliminating corruption in one way or the other. The demands to dismiss Cabinet members and personnel in high offices with tainted credentials, dealing with culprits of the recent Hajj,...

Anti-corruption strategies

Published in The News International on January 05, 2011: The government and opposition factions appear to be converging on a ten-point Agenda focused on eliminating some of the currently prevailing governance distortions in Pakistan. Articulated as a set of “Demands” by one particular opposition party, the points have been endorsed by others and have been admirably embraced by the incumbent federal government. The ten-points, per se, are non-controversial and there appears to be a broad consensus that action towards them will contribute positively in an environment where mistrust and malfunction are now deeply ingrained. This comment is aimed at explaining that whilst these points are significant stepping stones, and are important in their own right, they are nevertheless inadequate for addressing deeply rooted systemic issues, which can only be amenable to reform at a more fundamental level. Three points are being highlighted to elaborate this further. Six of the ten demands center on eliminating corruption in one way or the other. The demands to dismiss Cabinet members and personnel in high offices with tainted credentials, dealing with culprits of the recent Hajj,...

Risks and resilience

Published in The News International on January 01, 2011: At the recent meeting of the Global Agenda Council of the World Economic Forum in Dubai some of the top issues in the global risk landscape and their possible mitigates were highlights. Ironically, a few of us from Pakistan could relate to most systemic risks as being endemic to our sovereign environment, each of them inextricably multi-dimensional in their scope. As global experts underscored the salience of effective governance structures, accountability, and clarity in multi-stakeholder concerted action as the means of addressing these risks, one could not help reflect on ones own constraints within that space. Reflecting on these risks and the mechanisms that can ensure institutional and population resilience is part of what one should be doing at the turn of the decade. Against the backdrop of mayhem caused by Iceland’s Volcano and the recent unexpected weather on Christmas Eve, probably the beginnings of manifestations of the “inconvenient truth”, the agenda of climate change and the modest progress achieved in Cancun are now a major point of reflection, globally. Pakistan has recently learnt...

The vanishing ministry

Published in The News International on December 25, 2010: The Implementation Commission of the 18th Constitutional Amendment is due to present its final recommendations to the Parliament for approval next week. Statements issued in the run up to that have already indicated that subsequent to abolishing the Concurrent Legislative List, a number of subjects, inclusive of health, education, rural development, population planning, social welfare, culture, tourism, youth affairs, etc., will be fully devolved to the provinces and their respective ministries will be abolished. As per the plan, their service delivery functions are to be devolved to provincial departments and their planning functions entrusted to the Planning Commission. Health is meant to be devolved in the third stage of implementation in July 2011. This decision is part of a long-standing provincial demand and long over-due federal initiative to grant provinces their due share of autonomy. Devolving subjects to the provinces is also part of the drive to cut back establishment costs and reduce fiscal deficit, an objective, the International Monetary Fund has been actively encouraging Pakistan to pursue. In principle, grant of provincial...

The PDF premise

Published in The News International on November 22, 2010: Pakistan Development Forum (PDF) 2010 was convened at a time of unparalleled challenges—with several macroeconomic issues, a grinding fiscal crunch, competing priorities for resource allocations, an energy crisis, ongoing war, relentless insurgency, and an unprecedented need for resources in the aftermath of the worst disaster on this planet in recent history, characterizing the country’s needs. Within this context, pronouncements at the forum highlighted some windows of opportunity at the margins of these significant challenges. This comment alludes to six in particular, emphasizing that stronger stewardship is needed to reap the potential within these opportunities. The first is about development assistance itself, given that PDF is the key forum, which determines priorities for allocating development assistance in Pakistan. In this regard, commitment of the international community to express their solidarity with Pakistan is appreciable, specially since many donors are recovering themselves from the ravages of a recession and have many competing priorities at home for which they are answerable to their taxpayers. Commitments have been made despite donor fatigue and we hope pledges will...

Dengue – fears & imperatives

Published in The News International on November 06, 2010: The recent outbreak of Dengue, which is commanding widespread attention, is an important insight into several health and overarching governance issues. Before those are alluded to, a brief comment is offered on the current situation. It is indeed a sign of progressive attention to welfare that hotlines, round the clock media coverage, front paper trackers and policymakers’ responses and reprimands have been galvanized in response to a public health concern. 4,363 cases of suspected Dengue Fever have been reported in Pakistan with 2,062 confirmed cases and 15 deaths until 22nd October 2010. Let’s be reminded though that in the same country, hundreds of thousands of infants and mothers die needlessly every year; tens of millions suffer from hypertension and diabetes. If proportionate attention and resources are allocated and if decision-makers’ wrath and intolerance is energized in response, achieving health goals might become a pragmatic reality rather than an aspirational vision, which is what it is today. Let us also recall some facts about Dengue in terms if it being a public health threat...

The budget process

Published in The News International on October 23, 2010: Drawing attention to the budget process during the month of October may appear a little out of step specially when there are so many other governance-related storms whipping. A closer look however indicates otherwise. The budget process for a fiscal year starts in the month of October with the Ministry of Finance issuing budget calls to all the ministries and departments seeking detailed reports of expenditures and estimates of demands for grants. Subsequently, the standard momentum takes course with the process coming to fruition in June with the budget’s presentation in the National Assembly. Rallying cries to reform the budget process when the process itself is well underway doesn’t allow space for change. If change is being advocated for, now is the time to reiterate its importance so that the new parameters can be shaped in time. The budget process and the budget itself are critical this year round. Pakistan’s grinding fiscal crunch in the face of many existing competing priorities has been compounded by the unprecedented need to divert resources in the...

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