How to Aid the Health Sector in Pakistan

By Samia Altaf and Anjum Altaf

This op-ed appeared in Dawn, Karachi, on July 30, 2010. It was intended to initiate a discussion on the possible approaches to sector reform and is being reproduced here with permission of the authors to provide a forum for discussion and feedback.

We must state at the outset that we have been wary of, if not actually opposed to, the prospect of further economic assistance to Pakistan because of the callous misuse and abuse of aid that has marked the past across all elected and non-elected regimes. We are convinced that such aid, driven by political imperatives and deliberately blind to the well recognized holes in the system, has been a disservice to the Pakistani people by destroying all incentives for self-reliance, good governance, and accountability to either the ultimate donors or recipients.

Even without the holes in the system the kind of aid flows being proposed are likely to prove problematic. Over a half-century ago, Jane Jacobs, in a brilliant chapter (Gradual and Cataclysmic Money) in a brilliant book (The Death and Life of Great American Cities), showed convincingly how ‘cataclysmic’ money (money that arrives in huge amounts in short periods of time) is a surefire way of destroying all possibilities of improvement. What is needed, she argued, is ‘gradual’ money in the control of the residents themselves. While Jacobs was writing in the context of aid to impoverished communities within the US, she concluded with a remarkably prescient concern: “I hope we disburse foreign aid abroad more intelligently than we disburse it at home.

Notwithstanding our misgivings, we are realistic enough to realize that the political imperatives for further aid in the form of cataclysmic money are overwhelming – the states and agencies representing the donors and recipients and the non-state contractors on both sides are desperate for the leaky plumbing to fill up again under pressure and there are those who are salivating at the thoughts of where they will find new holes to drill. The putative beneficiaries in Pakistan and the tax-payers in the donor countries, those who should have the most to say, are the ones with the least influence on this merry-go-round of aid. Effective watchdog groups are conspicuous only by their absence.

In the light of this realization and the progress of the Kerry-Lugar bill, we had circulated a note to donor agencies, think tanks, and Congressional committees last year on how to ensure that new money does the least harm, and at least some good, to the health and education sectors in Pakistan. We are reassured to see that the central ideas are also reflected in the Signature Program for Health announced earlier this month during the most recent visit of the US Secretary of State.

While this program adopts the right approach, that of concentrating resources on the revitalization of key facilities rather than spreading them thinly across country-wide initiatives, we feel the need to spell out for public discussion the vision, its rationale, and the set of complementary activities that are essential to making these investments both sustainable and catalytic for the sector as a whole.

The central premise of our recommendation is that the gaps in rural health care are too large to be fixed in the short term while a focus on tertiary care is of limited benefit to the majority of the population. The district hospital forms the heart of the health care system in Pakistan. The weak rural health cover pushes all patients with even the slightest complication to the district hospitals overwhelming their limited capacities and making them visible symbols of system failure. In turn, the district hospitals are unable to fulfill their role as filters for the tertiary care facilities in the metropolitan centers. Only a major upgrade of the district hospitals would provide immediate relief to the health system while triggering the backward and forward changes that would deepen the reform process. This is the only intervention with the potential to unleash a new dynamic in the short to medium term.

The essential pre-requisite to using aid effectively is to use it to structure the change dynamic around a small number of discrete interventions that have very high impact, are easily manageable, need minimal involvement of the local bureaucracy for initiation, can be monitored by citizen watchdog groups, and can deliver immediate and visible benefits to marginalized groups in society. The limited number of district hospitals in the country makes this choice the optimal one in the circumstances.

In order to make these investments sustainable and catalytic it would be important to identify and put in place the upstream and downstream linkages and the complementary reforms necessary for the efficient functioning of a district hospital as the focal point of a national health care system. A focus on facilities alone would cause the initiative to wither soon after the funding ends. These complementary reforms would include aspects of governance, regulation, accreditation, staffing, compensation, vocational training, procurement, etc. The district hospital should be the nucleus for micro experiments in the systemic reform without which any sector-specific change initiative would flounder.

What we have not been able to stress to individual donor agencies but consider of over-riding importance is the recognition by the Pakistani policymakers that it should be the Pakistani state and not piecemeal programs of donors that should be ultimately responsible for a coherent long-term vision for the sector. Donor investments have to fit into and not drive the sector strategy.

Given the limited capacity of the state, one of the most effective measures to ensure efficient and coherent utilization of assistance would be to implement this sector strategy in a competitive format. For example, in the first iteration, the rehabilitation and management of five district hospitals each could be assigned to different bilateral donors in competition with each other and with the local public sector as well. The injection of a competitive dynamic would itself generate incentives for good performance that have been conspicuous by their absence to date. In addition, this format would also facilitate local experimentation with different practices in order to identify what might work best in the specific context of the country. This was the model underlying the emergence of the globally recognized stature and performance of the Indian Institutes of Technology.

Such an initiative would need to be supplemented by a plan detailing how and over what time frame the revitalized asset base would be fully integrated into the national health care system. This would require identifying the capacity building needs, administrative reforms, and the modalities of continued citizen involvement that would be required to ensure the sustainable operation of the refurbished assets. Aid need not be destructive if it is designed intelligently by the host government, implemented transparently by the contractors with public disclosure of budgets and milestones, and monitored rigorously by the representatives of tax payers in the donor countries and of end users in Pakistan.

Samia Altaf is a public health physician; Anjum Altaf is an economist.


  • Anjum Altaf
    Posted at 18:46h, 04 August Reply

    We have been asked to translate the suggestions in this op-ed into a step-by-step approach that can be implemented. Here is the approach we would recommend:

    1. Develop consensus on a sector strategy that sees the district hospital as the focal point that can generate the most sector-wide impact for the minimum amount of investment in the shortest possible time.

    2. Design a pilot phase in which one or two district hospitals are identified for revitalization in each province. Add one hospital each in AJK, NA and FATA, if feasible.

    3. All district hospitals should be eligible to bid for the pilot program based on pre-determined criteria and on meeting certain minimum requirements. This competitive process would inject a positive dynamic in the sector and create incentives for improved performance benefiting even those hospitals that are not selected for the pilot phase.

    4. GOP should assign the selected hospitals to multiple donors (say one to two each to USAID, DFID, AusAID, EU, JICA). This competitive format would generate incentives for good performance amongst the donors. Such a format was very successful in the case of the Indian Institutes of Technology in India.

    5. The donors should be required to submit a schematic of the approach they intend to follow to make the district hospitals successful nodes of the health sector in Pakistan. This would require spelling out the complementary reforms and upward and downward linkages necessary for the investments to be productive. All the donors have been active in Pakistan for decades and should be very familiar with these issues and requirements.

    6. When the pilot phase goes into operation the donors should make a public disclosure of the budget and the critical milestones to be achieved over the life of the project.

    7. GOP should also arrange to put in place a representative citizens group to act as a watchdog for each facility. In addition, a media committee should be formed for each facility to document and disclose the progress of the project to the public.

    8. At the end of the pilot phase the exercise should be evaluated by a team of international and national experts and the lessons learnt and best practices identified should form the basis of a much larger investment program following the same competitive format on the demand and supply sides.

    We would like readers to add their input so that a consensus can develop around an initiative to be implemented as the centerpiece of a long term strategy for the health sector.

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