IN Pakistan, political tensions between the federal and provincial power centres, often cloud on-the-ground technical achievements. This diminishes critical learning for the government to deliver better.
When pandemics threaten to overwhelm health systems, the crisis can catalyse new partnerships across the public and private sectors. In a decentralised Pakistan, pandemic planning, boosting medical supply chains and information sharing are joint functions of the national and provincial governments, whereas ensuring service delivery, diagnostics testing, case reporting as well as regulating services are provincial functions.
So where does the private sector fit in this administrative jigsaw? Pakistan’s health service delivery is dependent on private hospitals providing 34 per cent of inpatient admissions, private clinics providing 70pc of front-line consultations, and private laboratories over 50pc of the testing capacity. In addition, the supply chain is entirely reliant on private manufacturers/distributors/wholesalers; private transporters provide hospital referrals in areas devoid of a government ambulance network, and private institutions actively contribute scientific knowledge. So, the private health sector comprising philanthropic organisations, for-profit organisations, industry, and research hubs is not a sector to be ignored; it must be powerfully steered to meet public goals in times of crisis.
When pandemics threaten to overwhelm health systems, the crisis can catalyse new partnerships.
Sindh has the largest number of Covid-19 cases in the country — around 204,103 of 457,288 cases — and the highest concentration of Pakistan’s private sector. Sindh’s response during the first Covid-19 peak, based on public-private collaborations, provides important lessons for (i) the rest of the country on how to rapidly escalate engagement with the private sector during health emergencies, and (ii) to institutionalise private engagement for continuing Covid-19 waves and future pandemics.
Notwithstanding the larger federal-province political ups and down, the Covid-19 crisis opened a new window of joint federal-provincial action within at least the health sector to get the private sector on board. The pandemic catalysed inclusive advisory relationships with the private sector through federal and Sindh-based task forces for joint operations response. The domestic private industry was boosted by federal facilitation for the speedy production of medical supplies, whereas digitalised data-sharing of cases and hospital capacity across private and public providers guided evidence-based procurement of medical supplies by the federal and provincial governments. Private expertise was mobilised by both federal and Sindh-based task forces for quality healthcare protocols.
The engagement in Sindh went deeper. In Sindh, laboratory regulatory licensing was fast-tracked, meaning that private laboratories were able to take on 50pc of testing requirements. Proactive government negotiations in Sindh secured enough treatment in local private hospitals to meet surge capacity. Private hospitals partnered with the provincial government for critical-care training of public-sector hospitals. Digital partnerships with private firms in Sindh established virtual triaging platforms, and call and referral centres enabled swift hospital cross-referrals, whereas telemedicine consultations by private practitioners and public-sector universities supported government quarantine centres. A provincial Covid-19 relief fund in Sindh, jointly managed by government and private philanthropies, pooled private-public funding and procured medical supplies.
Not all areas progressed during the immediate fire-fighting response, and these provide important benchmarks to take forward the consolidation of the response for ongoing Covid-19 waves and future pandemic preparedness in the country. First, the government hesitated to control market rates at private hospitals and laboratories — which is necessary to ensure financial access for the less affluent — for fear of private providers withdrawing the needed treatment and hospital services.
Second, the government focus has remained on engaging the hospital industry, relatively overlooking general practitioners. The role of GPs and their integration into the downstream district government response are critical for front-line support, referral, risk communication and tracing.
Third, while national medical supplies production for PPE, handwashing and testing kits was meaningfully boosted, product regulation efforts are required to counter the uneven quality of local supplies.
Lastly, while the government drew on private clinical expertise, it must engage epidemiologists and public health specialists who are the cornerstone of epidemic response management in any country.
There are also essential lessons to be learned from how Sindh has been able to escalate public-private partnerships to respond to a health crisis. Sindh’s headway has been catalysed by a robust market of formal organised healthcare providers in the province, ongoing public-private partnerships initiatives, and proactive champions within the government. Mutual benefits helped bring the public and private health sector together — the government gained a positive image, and received free expertise, critical supplementary services and supply chains, whereas for the private sector the collaboration provided communication pathways out of a crisis, policy recognition, and new business development relationships. And common private-sector actors in federal and provincial task forces, helped in providing consistent messaging.
Transition is required towards longer-term delivery institutionalisation of private collaborations for pandemic response and prevention. The Global Health Security Index is a measure of a country’s capacity to control pandemics and other health threats that can impact society. Pakistan ranks 105th amongst 195 countries for global health security with an index score of 35.5. The score can be improved without huge effort — there is good latent capacity for laboratory, human resource and IT systems across public and private providers, but the governance architecture is weak. While Pakistan signed off on the GHS commitment in 2015, GHS governance forums are not functional. Pandemic preparedness exercises, upfront ring-fenced investment and reporting systems are yet to be institutionalised.
Yet the pandemic unlocked a policy window with the private sector on which to build a global health security response. These must be formalised and sustained through a collaborative governance architecture. Overlooking Pakistan’s extensive private sector is self-defeating in a country reliant on mixed health systems.
In order to work, public-private collaborations need to be framed on aligned goals. That is the challenge for the federal and provincial governments — to row the private sector towards common interests that can meet the public good.
The writer is a health policy researcher and faculty. This article draws upon a policy analysis study led by the writer for the World Bank.
Published in Dawn, December 26th, 2020