By Faraz Khalid, Health Systems Consultant at World Health Organization, Eastern Mediterranean Regional Office, and member of the HSG Emerging Voices for Global Health Thematic Working Group
In the next few months, Pakistan, the sixth most populous country in the world, is expected to undergo the second democratic transition in its 70- year history. Elections are expected to be held in August 2018 and politicians have already begun holding public rallies as a run up for their election campaigns. Political parties are gearing up to announce their new election manifestos. At this stage, it’s important to assess how the politicians are garnering support from their electorate. From a health systems lens, one can predict the achievements that will be boasted during the election campaigns by reviewing the health sector developments shared by the federal and provincial ministries of health (ruled by different political parties) against the promises made in the party manifestos in the 2013 election cycle. In this account, I will compare the attention given to the hardware vs software of the health system from one election cycle to the next. As commonly explained in the literature, health system hardware includes financial resources, infrastructure, technology, medical products and human resources for health; health system software encompasses procedures, values, interests, power distribution, relationships, and communication between stakeholders.
In 2013, the health section of five major political parties’ manifestos – Pakistan Muslim League (Nawaz), Pakistan People’s Party Parliamentarians, Pakistan Tehreek-e-Insaf, Mutahida Quami Movement, and Jamaat-e-Islami Pakistan – focused more on strengthening health system hardware – upgrading of district and sub-district hospitals, deployment of mobile health units, addition of human resources for health in rural areas, establishment of food and drugs testing laboratories, launching of health insurance programs, and enhancing the coverage of service delivery programs. Similarly, the developments projected on the websites of departments of health run by the Federal government, and the Punjab, Sindh, Khyber Pakhtunkhwa, and Balochistan provincial governments and the grey literature published during the last 5 years clearly show a tilt towards the addition of hardware into the system. A snapshot thematic analysis of the speeches made by the ministers of health in public meetings over the last year also signals a very strong focus on the hardware.
The decision to prioritize hardware over software makes sense both from electoral politics and technical perspectives. Since hardware is very visible, can be easily showcased to point out achievements, and can improve the public image in a relatively short time, politicians’ fondness to prioritize it can be easily understood. Pakistan is certainly no exception to this rule. Moreover, the country’s health system certainly needs immense public investments into the hardware, as the ratios of health workers, hospital beds, and outpatient facilities per 10,000 population, and governmental spending on health are substantially lower than the corresponding average values for other lower middle-income countries.
Nevertheless, prioritizing health systems hardware over health system software raises a few questions. Is not software needed, such as placing public health goals above private self-interest, transparency in procurement procedures, community participation and empowerment, crediting and striving for equity, intra and inter-sectoral coordination, awareness of power dynamics, sensitization of each stakeholder’s own legitimacy, role and practice in the system, relevant legislations and regulations, required knowledge and skillset? If all these are needed, why have these important software issues not been on the political agenda so far?
Let’s focus on corruption by way of example. Pakistan has been ranked consistently low in its public-sector governance and combatting corruption would be one type of policy to improve health systems software. According to the corruption perception index 2017, the country is ranked 117 out of 180 countries in a global ranking – not exactly an enviable position. There has been no recent comprehensive country level assessment for the health sector. The latest statistics published in 2006 revealed, however, that 95% of the population perceived high levels of corruption in the health sector and 96% of the users who sought services from public health care providers made informal payments. The reported underlying reasons for corruption in the health sector were the lack of explicit performance standards for providers, collusion in contracting, lax fiscal controls in public funds management, limited enforcement of rules and no sanctions, lack of accountability and oversight, and limited citizen involvement – most of which are related to health system software. Chances are not much has changed since 2006. In a country where domestic general government health expenditure makes up just 1% of its GDP, the significance of plugging corruption-related leaks is undeniable. From politicians to patients, “the abuse of entrusted power for private gain” needs to dealt with, not only in Pakistan by the way but globally, as corruption in healthcare is rife worldwide, according to a 2016 report.
For politicians, potential reasons for not prioritizing changes in health system software in a typical lower middle-income country context could be that such reforms require consistency, long-term commitment, are not readily visible, and sometimes threaten the interests of powerful constituencies (like political partners, bureaucrats, pharmaceutical companies, etc.), which may not always be politically feasible. While development partners have been increasingly focusing on improving governance and combatting corruption, their work has often been more normative. Less support has been offered to countries on the “how”, when it comes to dealing with corruption. In addition, civil servants, who usually get promotions based on their political loyalties rather than merit, often prefer aligning their work with short term political goals rather than setting the house in order (some would say ‘on fire’). Traditionally, with more funding options available for disease specific responses, strengthening the institutions has also not been high on civil society’s agenda. Further, there have been very limited tracer indicators developed for assessing cross-country and within country performance on the health system software situation.
Concerted efforts will be needed to ensure that the policy agenda combines the health system hardware with the required software. The forthcoming manifesto review meetings organized by political parties will be a good platform to highlight this need. Otherwise, the hardware added into the system may be used more for political mileage rather than health system strengthening.
Disclaimer: Views expressed in this article are those of the author and do not represent his official position