Dr Sania Nishtar2013-05-24T02:34:05-04:00Dr Sania Nishtarhttp://www.huffingtonpost.co.uk/author/index.php?author=dr-sania-nishtarCopyright 2008, HuffingtonPost.com, Inc.HuffingtonPost Blogger Feed for Dr Sania NishtarGood old fashioned elbow grease.Pakistan: Mega Misnomerstag:www.huffingtonpost.com,2013:/theblog//3.26445222013-02-08T07:11:52-05:002013-04-10T05:12:01-04:00Dr Sania Nishtarhttp://www.huffingtonpost.com/dr-sania-nishtar/
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 and have been ranked among the bottom two in the World Economic Forum's Gender Gap rankings for the last six years.
Recent education rankings based on the proportion of girls who have never been in school, place us in the bottom 10 countries. The 2011 Household Integrated Economic Survey indicates a widening income gap between the rich and the poor; the list goes on. It is not just 'outcome' indicators but also the 'process-level' indicators that do not inspire confidence. We are slipping on transparency ratings, competitiveness rankings, doing-business inter-country measures and democracy indices.
Why is this the case? What has gone wrong? Why can't we get our act together? Although a number of factors contribute to this quagmire, it is the misuse and abuse of three attributes of state governance that is the root cause of many of the problems we face today - politics, democracy, and accountability are the most widely misunderstood words in the country.
Politics refers to matters relating to the organisation of the affairs of the state. It is also considered analogous to the process of steering a country where a government assumes the controls of a ship. If politics is the art of navigating the ship of state, then fashioning the signs by which a steersman should steer is a function of political parties. This is where the key problem lies. Political institutions have a specific role, which centres on nurturing human resource and the strategies for the purpose of organising the running of the state and its organisations.
Since politics is also about gaining control of representative institutions, it can be understood that some level of power struggle and rivalries will be inherent to its functioning. Although Pakistan is not unique in the domination of power-play in politics, it is certainly exceptional in relation to the manner in which it has become integrated with the executive's functioning with decision-makers reaping the benefits of incumbency for re-election. Not only is this detrimental for governance, it has also eroded the capacity of political institutions with cult- and clan-based control.
The second misunderstood attribute is democracy. Democracy is not just about 'majority rule'; it is rather an amalgamation of many attributes. It is a set of institutional arrangements or constitutional devices. By this measure, Pakistan has achieved some progress since the 18th constitutional amendment has restored the constitution to its pre-military character. But that is not enough, since democracy is also about individual and institutional behaviours, characterised by respect for separation of powers and regard for evidence in decision-making.
As a value, democracy is closely related to liberty, equality, freedom and rights. Governments should be democratic not just in an institutional but also a social sense with attention to individual liberties, human rights and social justice. We must not rattle popular vote as a measure of democracy; we also must not regard as 'democratic' the 'consensus' between political factions over decisions that are mutually beneficial and driven by the status quo. Democracy has to mainstream the voice of all, and must uphold everyone's interest as well.
The third misnomer is 'accountability', which in Pakistan is considered to be synonymous with political exploitation, as illustrated by past history of accountability institutions. Accountability in state governance is quite different from that. Pakistan's politicisation of governance, rampant graft and a blatant disregard for merit are the causes of its quagmire. Tracked back, many of these problems have their origins in a lack of mechanisms that compel accountability. As a result of limited accountability, poor governance, mismanagement, inefficiencies and malpractices have become pervasive.
The thread of each adverse outcome in Pakistan today lies in a bad decision or deliberate oversight. From the burgeoning debt burden, the spiralling fiscal deficit, the energy quagmire, poor human development to the manner in which extremism has taken root in Pakistan, a chain of individuals in public decision-making roles can be held responsible, but are hardly ever held responsible. The accountability apparatus does not have the ability to engage in politically-blind operations. If we continue to regard responsibility, answerability, blameworthiness, liability and other attributes of account-giving, low level of importance that they have been receiving, governance will further deteriorate and we will continue to spiral downwards.
But it is not just the public system which is at fault. People are also to be blamed when they collude with the tax administration and circumvent procedures, when they are complicit with regulators in allocation of subsidies, licenses, quotas and price ceilings, or when they are in cahoots with public-sector procuring agencies, or are party to institutionalised pilfering now so characteristic of public functioning. Given the strategic significance of accountability, it is ironic that it has not been a legislative priority. Several iterations of an accountability bill have been in the legislative process. Perhaps it should be the first priority of a democratic government to get such a framework in order.
Pakistan is a country with enormous potential. While some pillars of the state suffer from malaise, the society continues to show remarkable resilience. The country is amply rich in natural resources, norms, the structure of organisations and institutions, even though they do not function well. Being a large market it offers huge investment potential. What is needed is some semblance of governance, and a certain level of policy predictability and consistency. Pakistan certainly has the ability to take off if its leadership commits to upholding the right principles in politics, democracy and accountability.]]>Polio and Pakistan: Great Trepidationstag:www.huffingtonpost.com,2013:/theblog//3.23946912013-01-02T04:35:28-05:002013-03-03T05:12:01-05:00Dr Sania Nishtarhttp://www.huffingtonpost.com/dr-sania-nishtar/
This tragedy comes at a time when the Independent Monitoring Board of the Global Polio Eradication Initiative, in its November 2012 report had just issued a positive note about Pakistan with regard to its efforts to curb Polio. Pakistan's Polio program reduced cases by more than 60% since last year (from 154 to 64). This indicated that things could turn around after the 2011 multidimensional negative trends where environmental surveillance indicated ongoing geographically widespread transmission and domestic numbers of new polio cases kept soaring. During 2011, Pakistan was also held responsible for international spread with virus causing outbreak in neighboring western China. Additionally, it was declared the only remaining reservoir of a rare wild poliovirus type, posing a risk for reseeding Asia.
The recent wave of killings is, therefore, a huge setback given that it has placed the 2012 gains at risk. It has also added another level of challenges to the existing multidimensional problems for vaccination, which includes: problems of geographical inaccessibility due to the armed insurgency in large parts of the country; refusals by parents to vaccinate on the mistaken notion that vaccination is forbidden in the religion; population movements across the vast and porous Pak-Afghan border; abysmal state of water and sanitation; the perception that immunization is part of a covert operation; and the 2011 commercial-interest driven smear campaign against GAVI, which despite the government's rebuttals helped to strengthen misplaced fears about vaccination--the list goes on. In fact, Polio in Pakistan today is not just a public health issue, but an illustration of the problems inherent within the state and the society.
Pakistan's polio eradication drive has also taken brunt of the country's governance challenges. Institutionalized collusion, geared to systematic pillage at the health systems level and absence of an accountability law make it very difficult to insulate polio from overall inefficiencies and malpractices which plague public sector functioning. Compounding these is the 18th Constitutional Amendment-led abolition of Pakistan's Ministry of Health and the lack of readiness of some provinces.
These challenges were already overwhelming for Polio eradication efforts but the recent wave of killings adds another and an unprecedented complexity--Polio vaccination risks becoming one of the epitomes of the anti-western sentiment in Pakistan. If that happens, the global gains in Polio eradication could be at risk. Much has transpired between the 1988 World Health Assembly (WHA) Resolution, which called for eradication of Polio by 2012, and global events around Polio Eradication in 2012, during which investment of more than US$ 8 billion, 20 million workers and implementation in 125 countries characterize the scale of the eradication effort. With the May 2012 WHA Resolution, labeling polio as an emergency, WHO's Global Polio Emergency Action Plan 2012-2013, and the Endgame Strategic Plan 2013-2018 now framed, the end is in sight. But so long as a single child remains infected, children around the world are at risk.
Pakistan now has a three-fold responsibility: addressing systemic polio eradication impediments, getting vaccination back on track with appropriate security cover for more 90,000 vaccinators, and reaching out to the masses with the right information to ally mistrust. At a minimum this would demand the will to prioritize action, the intent and ability of political factions to work collaboratively, and the ongoing injection of resources. With parliamentary elections forthcoming, all these will be in short supply.]]>Drug Regulatory Authority: A Case for Hope?tag:www.huffingtonpost.com,2012:/theblog//3.22704492012-12-10T08:50:03-05:002013-02-09T05:12:01-05:00Dr Sania Nishtarhttp://www.huffingtonpost.com/dr-sania-nishtar/http://www.heartfile.org/pdf/99_Mandate_to_regulate.pdf). In retrospect the lesson learnt from this experience is that decision-making should be guided by evidence, earlier on without the need for a catastrophic event to underscore its salience.
Now that the authority has been created, it is time to take stock of the safeguards that need to be built in order to make it effective. In this regard, first, it must be appreciated that desirable as it is, independent regulation needs robust and transparent governance or it is even more likely to fall prey to capture by vested interest groups than was the former Ministry of Health's-style of regulation, given that this is a highly regulated sector. It would be crucial to make appointments on merit, ensure technical competency and guarantee conflict of interest safeguards. The fact that there is a fine line between the policymaking mandate and regulatory prerogatives in this law creates all the more reason for transparency in governance. If there is a deliberate or inadvertent inattention to transparency and accountability in the governance arrangements of the authority, the consequences can be dire.
Secondly, with respect to potential weaknesses of the new regulatory authority, is the broader policy and institutional context that has to be brought to bear. The authority, no matter how well resourced, technically astute and independent--we hope all attributes will be ingrained over time--will not operate in a vacuum. Its primary purpose is to provide for "effective control and enforcement of the Drug Act, 1976", which is where there is a problem. The Drug Act has many exploitable covenants and other gaps that have emerged as a result of recent trends in technology, advertising, and WTO agreements. Moreover, traditional medicines prescribed by over 130,000 practitioners are outside of its ambit. The currently in-force Yunani, Ayurvedic and Homeopathic Practitioners Act 1965, under which traditional and herbal medicine is dealt with in Pakistan, does not provide for regulating products, a major gap. The Tibb-e-Unani, Ayurvedic, Homeopathic, Herbal and other Non-Allopathic Drugs Act, 2002 has been in the pipeline for over 7 years now and needs promulgation as a starting point to address this critical weakness. The new Act has brought devices and biological substances in the regulatory net, which is a positive and important step as they have remained outside the regulatory ambit and are an area where collusion and price gouging is pervasive. Presumably the Drug Act or another instrument will also have to be modified/updated with this in view.
Thirdly, the institutional infrastructure upon which the drug regulatory authority will be dependent for the execution of its mandate needs critical inputs to overcome existing constraints. Drug testing laboratories which are now rightly under the regulatory authority's wing need a major fiscal and technical impetus. In a human resource terms, the field force of drug inspectors on which the authority is still reliant is not only quantitatively paltry (250 inspectors to monitor over 600 manufacturing facilities and over 50,000 retail outlets!), but is also qualitatively weak in terms of capacity. Graft is the norm in regulation, both at the manufacturing and retail levels. To a certain extent, it is the grossly inadequate systems of compensation which fuel what can be labelled as 'subsistence graft'. These systemic distortions will have to be addressed by the authority as a priority. Also, innovative means will have to be adopted for implementing and incentivizing pharmacists' training. Currently there are around 200 pharmacists in the 50,000 retail facilities and the national capacity to train pharmacists will not be able to cover the gap in the next 20 years. A cross sectional survey conducted in the third largest city showed that only 19% of pharmacies met licensing requirements. Only 22% had qualified pharmacists, only 10% had temperature monitoring and only 4% alternative supply of electricity for refrigerators.
A final word of caution. As the government brings the implementation arrangements and rules of this Act to fruition, they should try and separate two kinds of malfunctions which result in the creation of spurious and falsified medicines. Such a separation is important from the regulatory and punitive perspectives. Within this context, I would like to draw attention to last week's major consensus article in the British Medical Journal with international authorship on which I happen to be a co-author. The paper is focused on the question of achieving international action on falsified and substandard medicines and proposes a global treaty to address this international menace. One of the four areas of emphasis of this paper relates to a new taxonomy of medicines, one that classifies medicines into legitimate and illegitimate. The paper divides illegitimate into two further categories; one being falsified medicines, those where there has been a criminal and fraudulent intent, such as wrong ingredients, bogus ingredients, or a deceptive design of the package. The other is the category which is indicative of regulatory or quality failure and this manifests either in unregulated or substandard medicines. To illustrate a case in point, the case of Isotab drug disaster in Lahore was a regulatory failure of the quality assurance systems of both the manufacturer and regulator and was not done with a criminal intent but serious nonetheless. Overlaps, notwithstanding, the paper recommends that the former category, "falsified", should be prosecuted by the justice system not just as civil negligence or regulatory violation but as true crimes worthy of serious punishment.
The new drug regulatory authority does present a case for hope, but if the systemic impediments and potential distortions and loopholes in the law are not addressed, it may lead to an even worse failure than what the earlier red-tape variant of drug regulation resulted in. The government must institutionalize the right checks and balances, safeguards and accountabilities. When harmful products get access to the market not only do they hurt the economy because of growth of the black market, and hurt bonafide businesses because of infringements on their legitimate prerogatives, they also harm and kill humans, and exhort significant suffering and ill health. Those that stand in the way of creating transparent regulation could well be the victims one day.]]>The New Wings of Developmenttag:www.huffingtonpost.com,2012:/theblog//3.20488782012-10-31T09:23:36-04:002012-12-31T05:12:01-05:00Dr Sania Nishtarhttp://www.huffingtonpost.com/dr-sania-nishtar/
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 catalyze investments--macroeconomic stability, rule of law, enabling legislation, facilitative regulation, and a level playing field so that businesses can be supported, thus creating jobs. But doing just that doesn't suffice. They must also address impediments posed by market imperfections so that jobs with the greatest development payoffs can be created.
Related to the idea of development assistance is the notion of "country ownership", heavily entrenched in the Paris and Accra Aid Effectiveness outcomes. Previously interpreted as developing country governments' prerogative on aid related decisions, this is also now being tacitly redefined. Barring exceptions, it is increasingly recognized that most G77 countries should utilize aid for improvements in productive assets and institutional strengthening, so that over time they are able to reduce reliance on development assistance. This vision of development places a huge onus of responsibility on governments rather than development agencies, which is how exactly it should be.
Secondly, with the global financial and sovereign debt crises as a context, there appears to be an emphasis on accountability not just for results but also for decisions. The importance of oversight, at the fiduciary and regulatory level, has become salient and the imperative to optimize the use of resources, minimize leakages from the system, and institutionalize fiscal responsibility and debt limitation. This has never been more compelling. There are some straightforward, but hard to deliver policy asks, of governments in this space.
Third, as planning gets underway to develop a post-2015 development agenda--the year in which the Millennium Development Goals will come to term, there may be additional asks of governments, as part of the world's new promise, the Sustainable Development Goals. While a sustained focus on poverty and the inclusion of environment, post Rio+20, is inevitable, other aspects of sustainable development are also likely to be included. Delivery on this new wave of global promises is not a matter of vertical thinking and silo planning. Most reviews since the MDGs have consistently raised the importance of strong institutional systems as a prerequisite for delivering on vertical targets. A whole-of-government and whole-of-society approach is being increasingly advocated, one which enables the creation of partnerships, not just with private entities and the civil society but also inter-governmentally in order to maximize synergy, draw on comparative advantages and foster collaborative division of labor. Partnerships are now regarded as a sine qua non of development for a whole host of reasons, amongst which harnessing of today's burgeoning of technological and scientific innovations in a globally interconnected world, is the foremost. For example, cell phones on their own, are termed as one of the most effective channel for reaching out to those at the bottom of the pyramid and provide services that help people lift out of poverty - by enabling unprecedented communication, information dissemination, tracking and financial services delivery. A powerful combination of factors is driving change in this regard in the developing world of which advances in technologies and applications and growth in coverage of mobile cellular networks is the most salient--and this is just one example.
It is therefore, up to astute governments to act inter-sectorally within the state system, as well as engage the right actors both within and outside of the development space in the private sector to forge the conditions that can tackle unemployment, step up long term inclusive growth, accrue the benefits of growth equally to populations, and take quantum leaps in development and poverty eradication.
This paradigm shift necessitates a whole new set of competencies for governments in terms of stakeholder engagement, and oversight and regulation. Results can only be as governments will make them. Shortsighted and graft-ridden governments cannot remedy their own deficiencies by seeking to yoke the private sector to their own uncertain cart.
Where does Pakistan see itself fitting in the new development landscape? Does it have the necessary conditions for investment and the ability to create jobs with the greatest development pay-offs? Does it have the capacity to reduce dependence on aid and address the central systemic barriers, which impede delivery on vertical targets, of which polio is currently the hallmark? Does the state system have the ability to act inter-sectorally to harness the potential within partnerships and help take to scale innovations that are burgeoning outside the state system? I leave it to the readers to reflect on these questions.]]>The World Economic Forum's Leverage in Healthtag:www.huffingtonpost.com,2012:/theblog//3.12565952012-02-06T04:30:14-05:002012-04-06T05:12:02-04:00Dr Sania Nishtarhttp://www.huffingtonpost.com/dr-sania-nishtar/
Such interactions are highly beneficial for the health sector, since there is a genuine need for reaching out to non-state actors in the midst of the many transformations shaping global and domestic health sector public policy.
The World Health Organization's 2010 report has placed Universal Coverage for health, centre stage. However, regulatory policy interventions are needed to achieve that goal in developing country mixed health systems, where private providers are dominant but remain undocumented, fragmented, and unregulated. The private sector also has a major role to play in fuelling technological advancement and Research and Development and can be incentivized for scaling up innovative development and financing models. All these strategies have the potential to overcome barriers to accessing healthcare and promote the twin goals of equity and quality. Developed countries can provide lessons on public stewardship models for private service provision, but a dialogue needs to get going to facilitate experience sharing.
Emerging market countries with increasing numbers of people entering the formally employed sector can create opportunities for private insurance companies capable of underwriting large populations into insurance pools. A change of this nature can help achieve universal coverage. So can the public private partnership model for developing healthcare infrastructure, which can be a viable option in the context of business globalization, and the opening up of markets, but appropriate policy oversight.
Appropriate public investments in health are an imperative. But these can be complemented by private investments, especially for infrastructure building in environments of diminished public budgets, albeit with appropriate safeguards. There is a significant health related investment opportunity in health care provision, retail, pharmaceutical and medical product manufacturing, insurance, social enterprises and medical education. With the right policy safeguards, many initiatives can create public-private resonance--offering commercially viable investment opportunities and models of health entrepreneurship while ensuring public good character.
However, governments require the capacity to tap the private sector's potential, and often sectors other than "health" have to be involved to meet the desired objectives. The case of infrastructure projects in the PPP financing mode is illustrative. They necessitate a transformation of the government's capabilities and governance capacities and can only be put in place with active involvement of Ministries of Finance and international development agencies. However, there are very few forums, where stakeholders reflecting this "whole of government approach" convene.
Last year, a high level UN General Assembly Special Session (UNHLM) put a new public health priority on the table--Non-communicable diseases (NCDs), where the solutions are partly in the hands of the private sector anyway. In fact, the UNHLM's Political Declaration has many covenants that called directly for action from the private sector.
Of course there are legitimate concerns around the role of the private sector in health, which underscore the need for building safeguards against any measure that can undermine the equity objective. Nevertheless, it is critical that we appreciate the potential of these public-private opportunities. As a starting point, stakeholders from diverse backgrounds need meaningful interaction to enable an understanding. That is where the World Economic Forum is bridging a huge gap.
But that is not all the World Economic Forum is doing for health. It is also contributing substantively in the normative and advocacy space. The case of NCDs is illustrative. WEF was a part of the global advocacy drive to address the world's main killer, a threat to human health development and economic growth in a major way. By identifying NCDs as the top ten risks to the world in WEF's Global Risk Reports for two consecutive years (2009 and 2010) it helped raise concern, globally, at a time when it mattered the most. It placed NCDs on the business leader's radar evidenced by WEF's Annual Executive Opinion Surveys, which feeds into the Global Competitiveness Report.
During the process that led up to the UNHLM on NCDs last year, WEF played a strategic role by building a strong economic argument and bringing fundamental evidence of the overall costs of NCDs in the public domain, in its report "The Global Economic Burden of Non-communicable diseases". One of its Global Agenda Councils is engaged in a process aimed at developing a new model to measure global progress--one that takes into account well being in addition to growth.
The World Economic Forum's ability to bring together public and private actors creates a much needed space to explore the potential of engagement with the private sector to achieve Health For All. Rather than 'privatization', 'marketization' or 'scaling up' private provision, the connotation should be one of addressing systemic barriers to stewardship of mixed health systems. Comparative advantages can be drawn upon and synergy exploited. By enabling communication, WEF is helping narrow the existing public-private divide in conventional multilateralism and is helping improve global cooperation and understanding. The insights can inform the design of new institutions of global governance.
]]>Pakistan - Innovative Financing For the Poorest of the Poortag:www.huffingtonpost.com,2011:/theblog//3.11010842011-11-17T19:10:10-05:002012-01-17T05:12:01-05:00Dr Sania Nishtarhttp://www.huffingtonpost.com/dr-sania-nishtar/
A country of nearly 190 million people, of whom at least 25%t live below the poverty line, 19% of the population is malnourished, including 30% of children under the age of five. The renewed floods are bound to add to these disturbing figures, with increased risk of water-borne disease, such as diarrhoea, which can have devastating consequences for young children.
The main burden, of course, falls on the poorest of the poor. Less than 26% of the population is covered for health care costs. Even in government-financed public facilities, a patient is expected to cover expenses such as user's charges, medication and consumables. And these charges are way out of the range of the very poor. They spend catastrophically, become indebted and are pushed into the medical-poverty trap. Many also forego treatment. Statistics show that healthcare costs are the most common cause of economic shocks faced by households. Most mixed health systems in developing countries face problems similar to Pakistan. More than a 100 million people become impoverished and a further 150 million face severe financial hardship as a result of health cares payments, globally.
Health equity funds can protect the poor against medical impoverishment, especially so when the insurance option is unavailable, unviable or does not fully cover healthcare costs. This approach is being used by us in our program, Heartfile Health Financing (http://www.heartfilefinancing.org), a system which is expanding the use of mobile telephony for health. In many developing countries, the mobile phone is becoming the information portal for healthcare workers. In Pakistan, I believe we lead the world in taking the use of mobile telephony to a new level - in developing a system to help fund the healthcare expenses of the poorest of the poor.
This is being accomplished through a recently established web-accessible technology platform and health equity fund, allied to a proper system of validating poverty and prioritising patients--the three components of Heartfile Health Financing. Requests for assistance by health workers, on behalf of a patient, can be made through an SMS template - but also by fax, telephone and letter. The technology platform has many unique features in relation to processing requests, targeting assistance, eliminating abuse, institutionalising accountability and empowering donors.
Once requests for assistance are received, the validation system swings into action. Phone calls can be made to friends, neighbours and family members - with the final step being the patient's unique identification number on the national database where all citizens are registered. The essential criteria is that only the poor and deserving must benefit - and payments are made at a level where health costs exceed 40 % of a household's capacity to pay in any one year. The system has also been configured to ensure that donors can view the use of their funds on a transaction basis- not least the administrative costs incurred. In fact, donors can track every penny they give.
The new system, is working in three hospitals, in Islamabad and Rawalpindi, Pakistan's twin cities. The number of patients seeking support is growing apace. Instead of waiting for months for a heart operation - which in itself can be fatal - a patient can be funded for surgery within days of the original application. Poor women who previously ran the risk of being taken away from the hospital bedridden for life because families could not pay for hip operations are being helped. And there are many many more.
These are initial steps on a long road - but there is no limit to the potential of this system. The technology infrastructure has been created with scale-up as a main consideration. Indeed, Pakistan's telecommunications infrastructure allows it to be used in even in the remotest areas of our country - and without the need for extensive and expensive field operations. This means that we can eventually take this system to all corners of our country.
Pakistan's impressive mobile teledensity makes mobile telephones a ubiquitous communications device, which can be leveraged for further health financing.
With the support of the donor community, and the strong culture of philanthropy available in Pakistan, there is now a real opportunity to help the poorest of the poor with their healthcare needs - and demonstrate to the world Pakistan's leadership in this field.
Dr Sania Nishtar is the President and Founder of Heartfile Health Financing, and the recently launched Sania Nishtar Health Fund which supports it.
www.sanianishtar.info
Related links
http://www.heartfile.org
http://www.heartfilefinancing.org
http://www.youtube.com/watch?v=ImeZU0srasI
http://youtu.be/liSKyboLAmU
http://www.heartfile.org/pdf/WHR_2010_HEARTFILE.pdf
http://www.heartfile.org/pdf/WHR_2010_HEARTFILE.pdf http://www.who.int/sdhconference/resources/draft_background_paper26_pakistan.pdf
http://healthmarketinnovations.org/program/heartfile-health-equity-financing ]]>Pakistan and Poliotag:www.huffingtonpost.com,2011:/theblog//3.10764482011-11-04T19:00:00-04:002012-01-04T05:12:01-05:00Dr Sania Nishtarhttp://www.huffingtonpost.com/dr-sania-nishtar/
The weight of the allegations is mighty. After 23 years of commencing the World Health Organisation-led Global Polio Eradication initiative, billions of dollars in investment, mobilisation of 20 million health workers and a population wide intervention in 125 countries, vaccinating more than two billion children, there are only four countries in the world which continue to harbour 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 far behind every other country in the world and there is every indication now that Pakistan will be the last remaining reservoir of poliovirus transmission in the world. What is additionally worrying is that poliovirus has started spreading internationally from Pakistan, as was evidenced by the recent outbreak of the crippling childhood disease in the western province of China, which WHO has traced back to Pakistan.
In many ways the case of polio eradication defies the notion that political will combined with allocation of sufficient resources will tackle any problem. That is not a given. The importance of functioning systems become apparent, as failures manifest - just as in the case of the global financial crisis and more recently the middle eastern democratic movements. Pakistan has consistently accorded high priority to polio, declared it a national emergency and allocated resources at a time of severe financial crunch, when an ongoing war, a relentless insurgency and two consecutive years of unprecedented flooding had created many competing priorities for resource allocations.
The weight behind the eradication drive led by WHO and supported by the international development community channeled in money despite the severely crowded out of fiscal space, internationally. This is evidenced by the recent innovative financing for polio by the Japanese government through a debt swap, the direct pledge for polio eradication in Pakistan by the Bill and Melinda Gates Foundation, and the consistent inflow from other spearheading agencies, WHO, UNICEF, CDC, USAID and Rotary International. The support to Pakistan has been unprecedented. Despite this, Pakistan, which was a global partner in eradicating smallpox in the '70s and quietly eliminated dracunculiasis on its own later, is now becoming a global pariah, because of its inability to eradicate polio.
The dynamics underlying this are complex. There is cross border movement of nomadic populations across the vast and porous Pakistan-Afghanistan border, both sides of which are conflict-ridden. Vast swathes of Pakistan's Federally Administered Tribal Areas, which constitute 12% of the country's territory and adjoining provinces, are plagued by an armed insurgency, where ongoing fighting severely limits access of vaccination teams.
This is compounded by the tragic disinformation about polio vaccination. Misinformed religious factions challenge the writ of the state and campaign widely against polio on the mistaken notion that vaccination is forbidden in the religion, that it impacts on fertility and that it is part of a conspiratorial design against Muslims. Such indoctrination orchestrates refusals on part of parents to vaccinate children, even when the facility is being provided by the state at their door step. Population 'mindsets' and 'movements' in these polio-trouble spots do account for a majority of the new cases. But to discount the contribution of other important factors would be incorrect.
The 33 districts which are labelled as high risk for polio, and those that adjoin them, also include central Punjab and Karachi, Pakistan's coastal metropolis, where failure to vaccinate because of poor health systems functioning and poor performance of the vaccination teams has been widely recognised. Malpractices such as absenteeism in public facilities, ghost vaccination teams, well-institutionalised pilfering from the supply chain, crony managerial appointments, collusion in monitoring records and embezzlement at the field level are all well known.
Concrete and commensurate action to institutionalise and compel accountability has just not been forthcoming to address these problems. These gaps in the governance of the Polio Eradication Program are an impediment to the effective translation of the National Emergency Plan for Polio Eradication into concrete action on ground and all the sensitization, awareness creation and commitment mobilization at the highest level, ultimately comes to a naught.
The same is being observed during the recent outbreak of dengue in Pakistan. Capacity of the public primary healthcare system, which anchors the field immunisation process, has been deeply eroded over the decades. Lack of policy consistency across governments has not enabled successive reforms at this level to take root and the resulting ambiguities arising as a result of the de-tracking and re-tracking from the local government system, a reform introduced in 2000, is not helping either. There has been no attempt to harness the outreach of the private sector, which delivers the bulk of healthcare in the country.
These inefficiencies are not all. Other constraints are evidenced in eight hours of load shedding interrupting vaccine cold chain, volatility in fuel prices impacting mobility of vaccinators, and poor sanitation and high population density leading to diarrhoeal diseases - still the third commonest cause of deaths in children in Pakistan - possibly interfering with vaccine absorption. Theories of vested interest at the administrative level to linger on with National Immunisation Days - the key instrument of polio eradication - because of the incentives linked to them, also abound.
Then there is the elephant in the room. Pakistan has recently abolished its Ministry of Health, under the 18th Constitutional Amendment, under which there has been massive devolution of responsibilities from the federal to the provincial level in Pakistan's federating system. This has led to lack of responsibility for national actions in health, a fragmented health information architecture, and low human resource morale because of deployment uncertainty, all detrimental for the polio eradication drive.
The systemic malaise, which affects vaccination is evident not just in polio but also more generally with 47% children fully vaccinated, after 17 years of a relatively well funded program rolling. Polio is, therefore, also an insight into the country's institutional capacity and the ability of its systems to deliver on programmatic endpoints. This is unacceptable and may come to haunt us in the event of an outbreak of an emerging or reemerging infection, which may be lurking in our neighboring region to the east.
Pakistan needs to put its entire organisational shoulder to the Polio eradication wheel on an emergency basis and get actors involved that can deliver in emergencies, to tackle this problem with institutionalisation of accountability as a key element. So long as a single child remains infected with polio, the global goal of eradication will not be met. While at it, we must also look inwards to put in place critically needed health system reforms, which will be vital for meeting any development target in Pakistan's mileu where social divides are widening at an alarming pace.
The author is the founder of Heartfile and the recently launched Sania Nishtar Health Fund. www.sanianishtar.info]]>