Posts Tagged ‘Policy’

Healthcare: Dubious Distinctions

March 20, 2018

By Samia Altaf

Two recent reports about Pakistan’s health system tell of deficiencies of far reaching significance.

The first, from UNICEF, confers on Pakistan the dubious distinction of registering the highest number of deaths in newborns (neonatal mortality) in the past decade. It is now number one in the world, climbing from number three, and ahead of Afghanistan and the Central African Republic. The second, a National Nutrition Survey, informs that 45% of Pakistan’s children are stunted, suffering from chronic, extreme, and irreversible malnourishment that causes permanent physical and cognitive deficiencies. What would this half of future generations be capable of with its severely limited capacity to learn even if the opportunity for education is available? It would fall sick much quicker and get better a lot slower creating a permanent burden on the already constrained health service delivery system.

The situation in other areas of healthcare, though not part of these reports, is equally grim. Measles continues to be endemic with 6,494 cases last year in Pakistan compared to 1,511 in poor Afghanistan and 513 in war-torn Syria. This is a stinging indictment of the national Expanded Program on Immunization, underway since 1988, which provides 50% coverage when 90% is minimum needed for herd immunity. Maternal mortality, deaths in women due to pregnancy related events, continues to be unacceptably high — 286 per 100,000 nationally and 786 in Balochistan. Deficiencies in large city hospitals with patients dying in hospital corridors or refused treatment have forced the CJP to step in the mess that should be cleaned by the Ministry of Health. The story of spurious drugs and the problems of DRAP are too familiar to need recounting.

Isn’t it remarkable that the marked decline in health outcomes has been accompanied by a sharp increase in the number of medical colleges and universities, hospitals, doctors, nurses, and midwives. Advances in technology and fancy apps have facilitated diagnosis and treatment. Donors continue their generous funding — Punjab has received a $65 million grant from DFID and the loan of an equal amount from the World Bank. This has  led to the current reform of the ministry of health — two ministers instead of one and two secretaries instead of one.

What is going on? Is it that we still don’t have enough doctors for our population? It is true that the doctor to patient ratio is half that recommended by the WHO. But then, why are so many young doctors unemployed? Why are so many people going to non-doctors? China’s population is five times that of Pakistan. Its Infant Mortality Rate (deaths in children under one year) is 12, seven times less than Pakistan’s and its Maternal Mortality Rate is 27, ten times lower. Yet, China has never tried to get its doctor to patient ratio up to the number recommended by the WHO.  

“The state needs to take charge,” exhorts an editorial in this newspaper (28.2.2018). But the state is firmly in charge. New programs are launched every few months and plans to control communicable diseases in children and provide services to women are articulated in documents PC-1s. Frenzied activity is manifested in fancy new programs such as the health card scheme, the formation of public companies to manage hospital waste, the engagement of expensive foreign consultants, all amidst regular pronouncements from government officials. The state has a panel of technical experts — eminent doctors working in its system — that has been advising governments for the past many decades and continues to do so now. The results speak for themselves. Why would future results be any different if the same experts continue as advisors?  

There are two sets of problems. First, there is no mechanism to critically evaluate the  recommendations of the experts to determine if they are in the interest of citizens or in the self interests of the experts. No oversight is provided either by citizens or by their representatives who either do not know how to monitor or don’t sufficiently care about the situation. Ironically, suo moto notices by the Court call on the same set of experts to provide answers to the problems they should be held accountable for.

Second, the Ministry of Health lurches from one leaking hole-in-the-dyke to another driven by donor is offering funding, bright ideas of dignitaries, or explanations called forth by the judiciary. There is no overarching systemic vision compatible with the country’s constraints and challenges, none that has stood the test of time, regime-change, or public scrutiny. The mindset that survives is that more is better – more consultants, more doctors, more beds, more ministries. The results are staring us in the face as documented in the reports mentioned above.  

Solutions at the margins in the absence of a robust public health system will not resolve the healthcare crisis. Just as more flyovers and underpasses cannot stay ahead of traffic congestion if the city continues to sprawl, increasing the number of doctors or hospitals cannot make up for the growing burden of disease in an unhealthy environment. Take air pollution as an example, where, on average, the exposure of Pakistanis to critical particulates is 6.5 times the safe level recommended by WHO. Asides from adding to morbidity, air pollution killed about 60,000 Pakistanis in 2012 making the country the fifth-deadliest in that category. Here too, we could be vying for first place with the commissioning of numerous coal-based power plants across the country.

The task is by no means impossible and much can be achieved with a simple focus on the provision of clean air, clean drinking water, safe sanitation, a critical education, and gender equality. In 2012, the Infant Mortality Rate in Bangladesh was less than half that of Pakistan’s although the rates were comparable in 1990. This remarkable progress in Bangladesh has occurred despite the fact that it is only two-thirds as affluent as Pakistan in terms of per capita income.    

The Pakistani story has been one of neglecting the basics and channeling funds to intermediaries on half-baked schemes that yield no benefit to citizens. The global rankings provide evidence that is impossible to refute.

The writer is a public health physician and author of So Much Aid, So Little Development: Stories from Pakistan. This opinion appeared in Dawn on March 19, 2018 and is reproduced here with permission of the author.

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Thank You, Donald Trump

September 8, 2017

By Anjum Altaf

Much as many are finding it hard to say anything good about Donald Trump, it cannot be denied that he has delivered the world a much needed wake-up call. Gone is the complacency about a whole host of topics that had seemed firmly settled – democracy, capitalism, globalization, trade, to name a few. Fresh thinking has been unleashed on a number of other issues – climate change, identity, immigration, terrorism, among them. There was dire need to rethink many of these and if the world required Trump to revitalize the debates, it has only itself to blame. In large measure, Trump is an outcome of not paying heed to what was going on under our noses but escaped attention because of the ideological biases of prosperous and uncaring ruling elites.

The ‘boiling frog’ analogy comes to mind: a frog dropped in boiling water will jump out but if placed in cold water that is slowly heated, it would not perceive the danger and be cooked to death. With the continuation of the mainstream status quo, had Hillary Clinton been elected president of the United States, there is little doubt we would have died in any number of ways because nothing would have changed till it was too late. Either climate change would have overtaken us before we reacted to its dangers while countries continued to bicker amongst themselves; or the neo-imperialist wars in the Middle East would have been intensified with the penchant for regime change to promote American values; or globalization would have have continued unabated enriching a few and reducing the rest of the world to a state of precarious uncertainty.

With Trump, we have been dumped into boiling water. Many of the simmering threats are being desperately examined anew, some, ironically, because  Trump has a much more cavalier attitude towards them. Take global warming, for example, where the Trump team is stocked with climate change deniers. It is precisely because the threat is now so in one’s face that activists have shed their complacency and are seeking new ways to revitalize their efforts. The same is the case with many other issues in which there has been a surge in theoretical revision, community activism, and grassroots mobilization. South Asians ought to look particularly carefully at Professor Amartya Sen’s critique of electoral systems based on the first-past-the-post criterion, a key contributor to Trump’s success.

One way to think of this radically new environment is in terms of a lottery. The status quo offered an almost sure bet of muddling through for another few decades before ending in catastrophe. Trump offers a fifty percent chance of instant extinction (his itchy fingers are on the nuclear button) and a fifty percent chance of revitalized political and social order in which many of the existing pathologies would have been addressed. Without the threat of imminent chaos, it is unlikely the resistance would have been galvanized in quite the manner that is now underway. Complacency and inertia would have continued to characterize the prevailing order with its almost inevitable consequences.

Consider, as an example, prevailing attitudes to democratic governance compared to its unremarked degradation. While Fukuyama hailed liberal democracy in the West as the end of history, Huntington lauded Ayub Khan as the ideal leader for the modernizing world that was not ready for democratic rule. Richard Holbrooke characterized the backwardness of developing countries as follows: “Suppose elections are free and fair and those elected are racists, fascists, separatists. That is the dilemma.” Fareed Zakaria was even more to the point: “Consider, for example, the challenge we face across the Islamic world. We recognize the need for democracy in those often-repressive countries. But what if democracy produces an Islamic theocracy, or something like it?”

The fact that democracy had produced a Hitler much before it produced any racists or fascists in the developing world was overlooked but now that it has produced Trump in the heart of the developed world, the doubts about the way democracy has evolved are out in the open and no longer considered the exclusive problem of backward non-White populations. American democracy in particular has morphed into a plutocracy quite at odds with its original design.

Or take the flip side of this alleged lack of fitness of the often-repressive countries, the unchallenged belief in American Exceptionalism. This rebirth of the White Man’s Burden in the age of neo-imperialism argued that the world needed to evolve towards American values while assigning a divine responsibility to the US for the purpose. Enlightenment was to be bestowed on the rest of humanity, making it fit for democracy through selective regime changes and by saving its women from the clutches of oppression.

As recently as a year ago, Obama had declared with pride and conviction that “I believe in American exceptionalism with every fiber of my being.” Now, barely six months into the Trump presidency, the veil has been ripped off American values regarding women and minorities and the reality of the US first policy that has wreaked havoc in the world exposed for all to see. As a result, European countries are already envisioning a future with a severely diminished political and ideological leadership role for the USA.

Nearer home, ordinary Pakistanis, if they pause to reflect, should also be grateful to Trump for calling out their country’s selective cat-and-mouse game with terrorism. Pakistan’s Afghanistan policy has been unsuccessful at best and at worst has imperiled the future of the nation via its economic cost, social damage, and political isolation. It would have continued unchallenged but for Trump raising the ante by laying aside the niceties and evasions that characterized the US-Pakistan dialogue under earlier presidents. The new bluntness and proposed regional realignment offer a glimmer of hope for an overdue questioning and a review under duress of Pakistan’s damaging security paradigm.

The world may not survive Trump, but if it does, many, including long-suffering Pakistanis, would have a lot to thank him for.

This opinion appeared in Dawn on September 5, 2017 and is reproduced here with the author’s permission.

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Urbanization: The Big Picture

September 4, 2013

By Anjum Altaf

Anyone wanting to understand urbanization needs to get past two major misunderstandings.

First, urbanization is not about individual cities – neither solving their problems nor enhancing their potential for growth. The end result of urbanization is indeed an increase in the population of cities but the term itself refers to the movement of people from rural to urban locations.

But which urban locations do (or should) people move to? That is a more important question.  What are the choices that exist and what determines the attractiveness of one location over another? Should public policy attempt to influence the spatial distribution of population by altering the attractiveness of different types of locations?

Second, the pattern of urbanization is not predetermined. People move primarily to seek work and therefore any change in the distribution of employment opportunities should alter the pattern of migration. Different industrial or economic policies should lead to different patterns of urbanization.

For example, an export-oriented industrial policy favors coastal locations; one based on high-end services might best be centered in big cities; labor-intensive manufacturing for the domestic market is suited to medium-sized cities; a big agro-industrial push strengthens the role of small towns.

It should be obvious that urbanization cannot be divorced from a discussion of industrial policy. But what exactly is our industrial policy and what role does it envisage for the various categories of urban locations – the big, medium, and small-sized cities and towns? Never having considered this explicitly, we have unplanned urbanization with suboptimal results – the big cities are overwhelmed with the influx of people and the majority of medium and small-sized cities are stagnant.

Eighty percent of Pakistan’s population lived in rural areas in 1950 when the economy was dominated by agriculture. Industrialization began to draw people into cities primarily because urban wages exceeded rural wages and better access to services added to the attraction.

The structural transformation of an economy – the transition from agriculture to industry – is accompanied by urbanization because most industry is located in cities. South Korea and Pakistan shared the same level of urbanization in 1950 but the structural transformation in the former is complete – in 2010, 80 percent of its population was urban.

The structural transformation in Pakistan and India has remained stunted by contrast – by 2010, only about 40 percent of their populations were urban according to official statistics, the consequences reflected in their much lower living standards compared to South Korea.

The stunted transformation in the subcontinent is both a source of opportunity and a cause of concern: the former, because the majority of the population is yet to migrate and therefore their choice of locations can be influenced by intelligent policy interventions; the latter, because there is little serious thinking on industrial policy that will influence people’s choices over locations.

The concern is compounded by the fact that arrested industrialization does not forestall urbanization. There might be no positive incentive to migrate but if rural poverty deepens desperate people would be pushed into cities. Such a poverty push has swelled a number of megacities in Africa. A similar push drives the export of labor from many regions in South Asia skipping domestic locations and moving directly to employment-generating cities abroad.

Poverty-driven urbanization is a consequence of weak industrialization. Employment shifts directly from agriculture to low-level services in informal sectors. The results are visible in slums in the big cities.

Healthy urbanization is not possible without industrialization whose policy parameters impact the choice of locations. This connection is ignored in the subcontinent. When challenged, policymakers are likely to argue that economics ought to be left to the free market which would best determine the locations of jobs and people would move accordingly.

This is contrary to experience. God did not create markets, human beings did. Almost all major markets in the subcontinent are outcomes of public sector investments (railways, canals, roads, villages) made by the British for objectives that are hardly relevant today. Opening up the Pakistan-India border or linking Kashgar to Gwadar would strengthen some markets and create others where none existed before. Each would affect the choice of destinations for rural migrants.

This raises a policy question: Where should jobs be located to yield an urbanization pattern that makes people better off? The question assumes that policy makers have a free hand in choosing locations and types of jobs. Unfortunately, that is not the case –one cannot, for example, relocate an impoverished farmer and expect him or her to adapt seamlessly to modern industry in a mega-city.

The reason is simple. Pakistan and India have not invested adequately in the health, education and skills of their rural citizens. Weak social and labor policies have severely limited the ambit of industrial and urbanization alternatives. Abstract theory might suggest that mega-cities are the most efficient engines of economic growth but with the existing endowment of human capital one might just end up with a transfer of rural poverty to urban locations.

The more realistic question is to ask what kinds of urbanization patterns are compatible with existing socioeconomic conditions. Should an informed policy favor rural industrialization? Should there be a phase of skill enhancement through agro-industrial development in small towns? Should medium-sized cities serve as intermediaries in a staged urban-industrial strategy?

These longer-term perspectives may appear suboptimal from the viewpoint of abstract growth theory but economists tend to forget that life is real and not abstract – one can only assume away reality at great cost to human beings.

The key takeaway is the following: Cities are not going to drive growth; rather, different types of growth will energize different types of cities – provided there has been adequate investment in human and physical capital.

Anjum Altaf is Dean of the School of Humanities and Social Sciences at the Lahore University of Management Sciences. This op-ed appeared in Dawn on September 3, 2013 and is reproduced here with permission of the author.

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Policy: Prescription, Analysis and Hot Air

April 24, 2013

There is a huge difference between policy prescription and policy analysis and the first without the second is a waste.

I come across this gulf everyday in discussions of issues like health or environment or urbanization but let me illustrate with an example from education.

So, I am reading this op-ed in a leading newspaper of the country and I am presented with the usual litany of woes: declining standards, lowest per capita spending in the world, ignorant teachers, ghost schools, different systems for rich and poor, medium of instruction, blah, blah, blah.

There follows a dire warning: this would destroy the country. (more…)

In Defense of ‘Against Research’

August 5, 2010

By Anjum Altaf

A polemical piece needs to be very finely tuned if it is to generate more light than heat. Against Research came up short for although the response exceeded expectations in terms of volume, the heat far surpassed the light. On the positive side, the knowledge that there is a constituency engaged with the issue gives me the motivation to try and explain myself with more care.

Despite the provocative title I should not have come across as being against all research per se. In the very first paragraph I stated that “I shall argue the case [against research] because I feel many of our problems stem not from a lack of new knowledge but from an inability to translate existing knowledge into action.” (more…)

Against Research

July 29, 2010

By Anjum Altaf

I write this article to question the value of research, a seemingly contradictory position for one trained as a researcher. Nevertheless, I shall argue the case because I feel many of our problems stem not from a lack of new knowledge but from an inability to translate existing knowledge into action. We are unable to convince decision-makers to act or voters to mobilise on the basis of available knowledge. To put my training to some use I shall explore the reasons for this failure which is both important and imperfectly understood.

Take poverty as an example. If we pile up all the reports that have been compiled on the causes of poverty in the country we would be well on the way to reaching the top of Minar-e-Pakistan. Yet agencies continue commissioning new studies year after year. I heard recently of a planned study on the drivers of rural poverty in Pakistan. The only variation I could fathom was the replacement of the word ‘causes’ by the more trendy ‘drivers’. On the other side, there is not a single study on why all the knowledge accumulated through previous studies has not been translated into action while poverty continues to increase. Nor is there interest in any such study. So, what’s going on?

First of all this supply of research is in response to demands that originate primarily outside Pakistan. International agencies rightly require every new loan or project to be based on current information, the gathering of which becomes the core of new research studies. Their purpose is served when the new loans or projects are signed off. It is not really the mandate of the international agencies to see to it that the research findings feed into policymaking within Pakistan. That should be the responsibility of the citizens of the country.

But there is much less demand for research from within Pakistan. The problems confronting the majority of the citizens are so basic that their solutions do not call for new knowledge. It is silly to determine yet again that x per cent of the population lack clean water and y per cent do not have access to safe sanitation. These facts have been known for years.

What is more relevant is to determine why these problems remain unresolved when their solutions do not require any kind of rocket science. Five thousand years ago there was a higher standard of service in Mohenjodaro. The same argument can be made for problems of education, housing and health.

At the same time decision-makers, barring the odd exception, are not used to making policy on the basis of systematic research nor are there institutional mechanisms that would call for discussion on the research underlying policy making. In fact, the need for research is hardly felt. Decision-makers seem to believe that they know all that is necessary to know and what they don’t know is not worth knowing.

To go back to poverty again, it is revealing how often eminent dignitaries inaugurate conferences by vehemently asserting that overpopulation is the cause of our poverty. It does not need any new research, only an observant eye to see China galloping ahead at over seven per cent year after year with a population over one billion and India beginning to accelerate with an equally large population.

At the same time there are numerous countries with very low populations and population densities mired in worse poverty than Pakistan. Much available research shows no obvious correlation between poverty and population or population density which would be a much more sensible indicator to use.

If decision-makers are so impervious to available knowledge what is the point of carrying out new research? The question we have to ask is why does research have so little impact and what do we have to do to change the situation? This would be the kind of indigenous research driven by our own concrete realities and much more relevant to our future.

We face a two-sided problem. On one side we have the majority of our population which is unfamiliar with the language in which most research questions are posed and findings reported. On the other side we have decision-makers who feel they already know what there is to know. In our oral culture, lukewarm to the written word, the worldview of both is shaped by popular wisdom which is renewed very, very slowly. That poverty is caused by overpopulation was the popular wisdom of almost fifty years ago. It still pervades the thinking of influential people today who have not come across all the subsequent research or opened their eyes to observations that prove the theory false.

What researchers have to do is to allocate more effort to ensuring that available knowledge permeates popular wisdom much more effectively and helps update it much more rapidly. This is a challenge unique to our situation and it would not be met by setting up research and policy institutes, publishing journals and holding conferences that are a pale imitation of the research culture of countries where the concrete realities are very different.

I am exaggerating somewhat to make the point that academic research is a particularly blunt instrument for social change in Pakistan. Interested individuals should continue to research to satisfy their curiosities or to prepare for careers in countries where such endeavours yield professional satisfaction. Research is also needed where clear knowledge gaps exist and more so in areas of the hard sciences. Thus, for example, the impacts of new types of chemical pollutants and the breeding of disease-resistant crops remain areas where continuous research is warranted.

But in the social sciences we may have gone beyond the point of diminishing returns and reached a state of habitual mindlessness in researching because that is what we have been trained to do. There needs to be an equal focus on getting the most out of existing knowledge and in making that knowledge matter.

This article was written when the author was a Visiting Fellow at the Sustainable Development Policy Institute in Islamabad. It appeared in the Daily Times, Lahore, in January 2004 and is reproduced here with the author’s permission.

 

Assessing Kashmir Policies

July 10, 2009

As a follow up to our brief debate on the Kashmir issue, I wish to propose an exercise that evaluates the Kashmir policies of the governments of India and Pakistan and also puts our own objectivity to the test. Such an exercise could yield an awareness that might enable us to move the discussion forward.

What I propose is the following:

For the first part of the exercise stop thinking of yourself as a citizen of your country. Consider yourself an external examiner (ideally from Mars) who has been invited to evaluate the Kashmir policies of the governments of India and Pakistan, respectively. (more…)