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Who shapes health policies?


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IN a country where policies are formulated in an ad hoc fashion and are designed to promote the interests of a vested class rather than of the people as a whole, it is creditable that there are researchers trying to inject some rationality into the decision-making process.

That is how I see the move by the Research and Development Solutions, an organisation working on collecting information, analysing it and sharing it with concerned parties. ResDev’s focus is on health, specifically maternal and reproductive health and immunisation. Above all, the research is done professionally under the director Dr Adnan Khan.

And who would deny that our health policy making leaves a lot to be desired? With a measly 0.7pc of GDP being assigned for the health sector in the official budget, Pakistanis end up incurring the heaviest out-of-pocket expenditure on health in South Asia. It does leave one wondering as to how policies are made.

ResDev’s latest research promises to be an innovative one and might prove to be very revealing as well. We will certainly learn how governments make policies. With a daunting title Maternal-Child Health Decision Making Processes and Outcomes in the Public Sector: From Theory to Action: How Does it Work, the study will seek to analyse the factors and the actors that determine health policies and their outcome.

Before beginning work on this study, Dr Adnan Khan decided to hold consultations with various stakeholders to decide on the parameters of the research and the people who should be approached. At the Karachi consultation, there was a diverse group that was collected ranging from NGOs, health and population department representatives, medical practitioners, politicians and media persons.

The discussions provided food for thought and one hopes that the research outcome will help reduce the disconnect between policymaking and implementation which has proved to be the bane of Pakistan’s efforts in development. Some influences have been widely recognised: donors have their own agendas and they seek to influence the policies and their outcome.

Research is said to be transformative yet it is not always geared towards advocacy and strategies are not always defined. In fact many policymakers have complained that they do not understand the jargon used by the researchers. Since ResDev has promised an analysis of the existing policies as well, this survey will be of great public interest.

The researchers are quite comprehensive in their approach and plan to include stakeholders across the spectrum to collect information and analyse the policymaking process. This is important considering that our policymaking processes do not strictly follow the regulatory framework that has been formulated.

The researchers at ResDev appear to be fully aware of it and that is why they speak repeatedly about the role of the political economy in decision-making.

What emerged clearly is the competitive relationship between the population department and the health department with each accusing the other of neglecting its duties and thus undermining the other’s work. It reminded me of what UN special adviser Dr Nafis Sadik has been saying for decades now that not keeping population planning under the health umbrella was one of the structural disasters enacted by Pakistan’s planners in the early years. Although last week there was some talk of mergers of programmes taking place, these were more of an administrative nature.

Three key players were not identified as participants in the research. They include the practising clinicians (not health administrators) as suggested by a gynaecologist who was present at the meeting, besides the public and the pharmaceutical sector.

It is something so typical of Pakistan that those taking a policy to the end beneficiaries, the people, are never consulted. For instance, teachers’ opinions are not taken when framing education policies. Similarly, it would be a good idea to talk to the public to determine how the government functionaries are performing and their relationship with the public. Also missing from the research survey is the pharmaceutical sector which is known to play a not very virtuous role in health policies.

Another dimension that needs very careful monitoring and verification if the research has to be authentic is that of data collection. Along with our poor records, the public is also notorious for its amnesia when it comes to dates, numbers and basic facts. We are a nation that lives in some kind of timelessness. Surveys can be a nightmare. One hopes ResDev will address this aspect and brief its researchers well. Departments that are quite cavalier about maintaining records should be thoroughly grilled if discrepancies are discovered.

The final question that will be asked is: will the policymakers take note of the research findings and recommendations? We know the fate of the best policies so diligently framed. Many would still remember the White Paper on Education drawn up by Javed Hasan Aly after a backbreaking exercise when he travelled all over the country with his team to determine what will work for our people. Even before he had finished his work he was “advised” not to question the official policy and produce results conforming to what the government — in those days Musharraf’s — believed was best for the country.

Yet such independent research is important and should be carried out irrespective of what cynics say. It will be instructive to learn how governments make policies in the social sector. If nothing comes out of it, ResDev can at least rightly claim, “We tried”.

Comments (2) Closed

a.k.lal Jun 26, 2013 12:15pm

with whom is your army fighting, your own people. this is police job. now make your defense budget zero, increase police budget if needed. nationalise all army and army officers wives pseudo enterprises. money saved to be spent on education, healthcare, women and child care and similar schemes. and after five years you lead the asian economy

Ali Hashim Jun 26, 2013 07:43pm

I had written a couple of months ago on the issue of whether more budget allocations to the health sector would result in better service delivery. I quote a few points and would be grateful if they are also factored in.

It is a common assertion that increasing the health sector and education sector budget allocations will increase the quality and scope of service delivery in these sectors. This, I think is a popular mis-conception. This concept is NOT applicable to all situations and countries.

In highly corrupt governments, the amount of resources that finally trickle down to the end user are only a very small fraction of the total allocation. The rest is lost to leakages due to corruption. This means that increasing the budget allocations in these sectors in such countries will ONLY RESULT IN INCREASED OPPORTUNITIES FOR CORRUPTION and loss of resources unless the service delivery mechanism is changed.

INDUS HOSPITAL in KARACHI, a fully funded charitable 150 bed facility financed through donations, which I visited recently, operates on an annual operating budget of US $ 10 million per year and has been set up at a capital cost of approximately $50 million. It delivers world class health service facilities to about 1500 patients per day free of cost. There are several other facilities such as this operated by NGOs in Pakistan. In fact, in some Government Hospitals, such as the Civil Hospital in Karachi, NGOs operate key facilities such as an operations theater complex, through donations, very efficiently, while other facilities in the same hospital are in a dire state. The health sector budget allocations for a mid-sized district in Pakistan are much more than the amount spent by Indus hospital with very little to speak of in terms of service delivery. Most of the budget allocations are lost to corruption.

The answer to this conundrum is that the service delivery mechanism needs to change. We observe that when funds are put at the disposal of NGOS wth a good track record one achieves good results.

For facilities run from budget funds, Government outsource the service delivery to NGOs with a good track record who have the credibility to manage that operate these type of facilities. This concept is being tried out for some facilities operated by the Social security administration in Iran. Government and civil society, together, can set up mechanisms to ensure that the service delivery is up to standard.