July 30, 2010

Even though the cover of Sania Nishtar’s book,Choked Pipes, does not make one “pick it up instinctively” as an ex-senator rightly pointed out at its launch in Karachi, the content of the book, however, makes it difficult to put it down. The treatise serves not only as an eye-opener but also as a consolidated view of the healthcare system of Pakistan.

While looking for answers regarding the “underperformance of the healthcare system” and the rampant corruption that has taken place for the past six decades, not once has the author stooped to regime-bashing in her analysis or pointed fingers. Nevertheless, she has delved deep into issues that have been ignored for a long time by the many regimes that have come to power in Pakistan.

The result is a comprehensive review of the healthcare system, consisting of a heavy dose of facts and figures, which is presented simply, bringing home the point that reforms are urgently needed. Nishtar analyses the past, present and future of the healthcare system in Pakistan and the many political ups and downs stemming from a regular shift in regimes. These shifts caused the state to focus more on short-term goals, based on the symptomatic treatment of the problems, instead of zeroing in on the root causes.

With news stories of doctors being beaten up by angry attendants making headlines regularly and a persistent plague of malpractice in the field of medicine, the book could not have come at a better time. Many countries in the West are revisiting their health policies as well, and there is a dire need to reassess and address the ongoing problems in Pakistan’s healthcare system. And it’s not too late, says Nishtar. Reform is possible.

Corruption is said to be one of the major obstacles to a nation’s social development. And the health sector is, unfortunately, not an exception. Nishtar, while understanding the challenges in confronting corruption in the health sector, writes that “the malpractices, including staff absenteeism, dual job-holding and theft of supplies,” common both in the private and public health sector, need to be addressed immediately. She acknowledges that reform within the health sector is dependent on the “effectiveness of overall governance and political stability.”

For a state to assert its authority, it needs to invest in its institutions, and the strongest of them is the judiciary. Despite many laws regarding corruption and malpractice, implementation remains a problem. The health sector is a part of the state and is immensely affected by the lack of transparency and accountability in it. A strong judiciary ensures transparency on every level and if that is weak, it will weaken other sectors as well. For this, Nishtar proposes reforms within political institutions and writes that opening avenues for seeking redress, and at the same time strengthening the judiciary itself, will help in countering malpractice and corruption.

At the same time she recommends a need to review the broader legislative agenda because that will ensure “overall transparency in state governance.” She further points out that Pakistan does not have laws to deal with white collar economic sabotage or to protect whistle-blowers, which she writes is needed as “it will encourage citizens to come forward and report incidents of corruption.”

In order to ensure transparency at all levels, she suggests a multi-pronged strategy to counter corruption: planning strategically and reviving the long dormant National Anti-Corruption Strategy (NACS); bridging the gaps in institutional mechanisms and institutionalising and encouraging integrity-promoting measures by ensuring that cabinet members do not have a “conflict of interest in terms of major business involvement, relating to respective ministries.”

While the prevalent threat of terrorism and the government’s focus on it takes centre stage in Pakistan, Nishtar points out that the nation is more in need of “epidemiological security from re-emerging infections.” She gives the example of avian influenza that re-emerged in Khyber Pakhtunkhwa, and writes that the recurrence of the virus means that there will be more cases in the future as well. She argues that the world is already grappling with issues related to food, water and energy along with terrorism, which together have made it unable to fulfill the basic needs of the people. To add an “impact of a disease pandemic in a global situation will be catastrophic.” This is where the nation should leverage the “WHO’s Disease Early Warning System and ongoing Field Epidemiology and Laboratory Training Programme,” says Nishtar.

Apart from political conflicts hampering the process of healthcare reform, Nishtar discusses the country’s lack of human resources. She writes that Pakistan has a reasonable supply of doctors, but a shortage of nurses and midwives has held back timely care to the people. This cause and effect leads to urban migration, putting tremendous pressure on the ailing healthcare system of cities such as Karachi that already have trouble treating their huge populations.

Nishtar tops off her thorough analysis with an ambitious multidimensional reform agenda, which she asserts should be pro-poor with “decentralised management and governance of public hospitals.”

Choked Pipes succeeds on many levels. Not only is it a useful reference book for those looking for insight into Pakistan’s healthcare system but it also can be used by policy-makers outside of Pakistan. “It is written not for a single country but is relevant for the intractable health problems of the developing world,” writes Nobel Laureate, Dr. Bernard Lown. Still, for Pakistanis it presents hope through a detailed action plan — and in these times of crisis, hope can be like a shot in the arm.