'Increasing public health spending alone won't cut it; need transparency, accountability', Dr Sania Nishtar

Dr Sania Nishtar is a well-known Pakistani healthcare professional, scholar and health reforms advocate. She is the founder and President of Heartfile, an independent health policy NGO think-tank based in Islamabad. She has been associated in various capacities with global organisations like the World Health Organisation, World Economic Forum, the Clinton Global Initiative and the Global Alliance for Vaccine Initiative. She is a regular plenary speaker or chair at global health meetings.
Dr Sania received the presidential award of Sitara e-Imtiaz in 2005. She is also a recipient of various international awards, including Global Innovation Award (Rockefeller Foundation, 2011), and European Societies Population Science Award (2005).
Following are the excerpts from Dr Sania's recent, detailed discussion with BR Research on the issues of health and governance:
BRR: How does a country's healthcare system bear on national productivity and socio-economic progress?
SN: A sick workforce is an unproductive workforce. Recent data shows that the global economic impact of illnesses is to the tune of trillions of dollars - not only in terms of lost productivity, but also in the form of costs of care. A recent global report has highlighted astounding estimates of impact. For example non-communicable diseases alone (a collective name given to diseases of the heart, lung, diabetes and cancer) are projected to cost over 30 trillion dollars over the next 20 years, globally. Loss of an additional 16.1 trillion dollars is also projected over this time span due to mental health conditions.
These costs are catastrophic for populations; they push millions of people below the poverty line and escalate healthcare costs, nationally. Many factors are contributing to this trend-ageing of the global population, rapid unplanned urbanisation and the globalisation of unhealthy lifestyles. Fortunately, these diseases can be averted and economic losses can be reduced by billions, but governments need to make the right policy choices and need to invest in prevention and health promotion effectively.
Many developing countries, including Pakistan, bear the double burden of disease, with communicable diseases and maternal and child health conditions taking a toll on the one hand and the burgeoning trend of NCDs on the other. Let's not forget the potential impact of emerging and re-emerging infections on the economy, to which Pakistan remains vulnerable. In the past, the transnational spread of SAARS and Avian influenza crippled economies, and billions of dollars were lost by countries in the tourism, hospitality and transport industries. We need to be mindful of Pakistan's vulnerability with respect to the post-devolution fragmentation of health information which may weaken our ability to be responsive in case of a future outbreak.
BRR: What is the current state of infrastructure and quality of care in the public health system in Pakistan?
SN: Pakistan's Mixed Health System has a strong post-colonial imprint with the British 'National Health Services' model operating - but with many gaps. The interaction of three factors has created many problems: inadequate state funding, a burgeoning, unregulated role of the private sector, and lack of transparency in governance. Chronic under-funding of the state's public health infrastructure is a major fault line. As a result, health providers in the public system cannot be remunerated adequately. Better incentives in the private system lead to dual job-holding, absenteeism and the 'ghost worker phenomenon'.
Infrastructure of public facilities has not been maintained, with dilapidation as a result. In such an environment of under-provision and poor provision by the public sector, market mechanisms come into play to meet the ever-growing demand of burgeoning populations. The resulting out-of-pocket payments, coupled with rampant unethical provider behaviours do the rest of the damage. The situation is complicated further by rampant collusion in procurements, preferential treatment in staff deployment, and state capture by the elite, which biases norms towards issues to obtain selective benefits.
Pakistan has a wonderful public healthcare system in terms of its design - it's just that it is overstretched and fault lines have emerged overtime! There is systemically ingrained collusion at every level. We need to fix the system's inherent flaws, by ingraining transparency and accountability, and by minimising collusion. The title of my recent book on Pakistan's healthcare system is 'Choked Pipes' - for a reason. The plumbing and the piping is there, but it is clogged - and there are ways to clear it.
Options to reform the system exist, but there are certain prerequisites. Debt limitation, fiscal responsibility, measures to broaden the tax base, pro-poor growth, overall transparency and effectiveness in governance, and policy consistency, are critical to achieving success in any reform. Of course these are big ticket measures but their impact could be equally broad based.
BRR: Are you making a case for more government investment in public health? What options for reform exist and what about the private sector?
SN: Increasing the base of public sources of financing for health is critical, but this alone will not suffice. There has to be a conscious effort to ingrain transparency in the use of resources. There are organised channels of pilfering resources from the system that must be plugged. In addition, there are some specific measures which can be taken in the short term. For example, through regulatory interventions in the labour market, the base of health and social protection for the informal employment sector could be broadened; management re-engineering can improve performance at public health facilities.
Private sector outreach can be harnessed to deliver public good through contracting, franchising and other arrangements. Technology and innovations can be harnessed to secure the distribution chain, make procurements transparent, optimise time and connectivity in health information systems, and bridge gaps in training, continuing education, and information dissemination. There are many more specific policy interventions, which stand alone, can make a difference,
BRR: Health became a devolved subject following the 18th Constitutional Amendment in 2010. What kind of an impact did it have (or is going it have) on the country's healthcare system?
SN: As a researcher, I would say it's too early to tell. We need to give it more time, and besides, some objective parameters must be chalked out for assessment. Currently, I am conducting a study where I am looking at 15 different indicators for the 'before and after' analysis. This will provide a reasonable assessment of the impact of devolution on various aspects of healthcare. Of course, we all have anecdotal insights, but we need to be objective in our analysis.
The 18th amendment was a policy choice and it has already cascaded into action. We need to focus on what needs to happen next. Specific, required actions stand out in this regard with respect to the health sector. First, it is critical that provincial capacity is built and that the right checks and balances and accountability are ingrained, in public finance management and service delivery. Centralisation of powers in the provinces is something that we need to guard against in view of the disarray the local government system is in.
There are a set of imperatives at the federal level as well. It is critical that national roles in health are appreciated, such as health information, health regulation, compliance with international commitments, and elements of national policy, in particular overarching norms, norms of care, inter-sectoral action, trade in health, health technology and disaster response. These functions cannot fall in the purview of provincial mandates and need to be federally retained. There are 28 federal countries in the world and not even one of them is without a federal co-ordinating arrangement for health.
I am fully cognisant of the political and constitutional imperative of provincial autonomy in Pakistan's federating system, and as such, am fully supportive of provincial autonomy. But it is also important that in today's globalise world, the role of the centre in a federal system is well defined and that we have appropriate institutions mandated to deal with them. The committee charged with the role of following up on the 18th amendment could, explore the option of a health division, which is constitutionally permissible, resonates with the spirit of devolution, and will allow consolidation of responsibilities related to health. If we fail to create apex responsibility, we risk fragmentation of capacity, the result of which could be dire.
BRR: What are your thoughts on the polio debacle in Pakistan?
SN: We are dealing with polio not just for ourselves and our children, but for children world-wide. So long as there is a single child with polio, the world cannot meet the eradication goal on this planet. That's what it boils down to, as more than 190 countries have eradicated polio. There is a very clear indication that Pakistan now runs the risk of becoming the last remaining reservoir of endemic poliovirus transmission in the world. To be fair, the government has attempted to put its entire might behind the polio drive. The development partners are fully supportive. Yet, we are unable to eradicate, and the inability to do so indicates complex systemic constraints.
The issue in conflict-ridden areas is not just a matter of constrained access due to the law and order situation. There are organised factions that campaign widely against polio vaccination, effectively orchestrating parental refusal to vaccinate children on the mistaken grounds that vaccination is forbidden by religion, that it causes infertility in populations and that it is part of a conspiratorial design against Muslims. Indoctrination of this philosophy has been one of the most important factors in undermining immunisation activities in many parts of KP and the tribal areas. Addressing this necessitates changing mindsets, which may not necessarily be amenable to short-term measures.
Also the performance of the field outreach teams has to be taken into consideration. That falls on a spectrum. Abuse, pilferage, absenteeism, ghost workers, informal payments, outright graft and systematic collusion at several levels are pervasive and undermine efforts. It is evident that weaknesses in health service delivery and broader issues in health governance are responsible for the failure to eradicate polio.
There is a very heavy, global connotation of this failure. It could be a huge stigma not just in terms of jeopardising world-wide disease eradication efforts but also in terms of our capacity to deliver on other international targets. Dealing with polio is relatively simple - you have to deliver drops with a network of health workers. With the millennium development (MDG) goals, the situation is far more complex. We need to critically reflect on our inability as we head towards 2015, the MDG finishing line, even as the world gears up for the Sustainable Development Goals - the world's next promise, which we will also be expected to be a part of.