WHEN people moan about weak health governance and corruption in the health sector, I remind them it is a small piece of a larger problem. Fixing governance issues in the health system has its limits. Still, one should not give up and be mindful of the larger context. One cannot build an island of good governance in the health sector alone when it is surrounded by an ocean of bad governance on a high tide where undressed big boys are ski boarding. The IMF’s recent damning report, Pakistan: Governance and Corrup­tion Diagnostic Assessment, explains the high tide.

Apart from giving staggering numbers for the termite of corruption, which has built its mounds and subterranean nests in our society, it also raises a shrill cry over the absence of any meaningful reforms, which each of the four IMF programmes in the last 10 years have flagged.

Let’s first talk about the scale of corruption. The IMF analysis shows that Pakistan is losing between a five to 6.5 per cent of GDP to corruption which is a direct consequence of weak governance. In other words, Pakistan could have generated a GDP increase of between 5pc and 6.5pc by implementing governance reforms.

Let’s see what a 5pc to 6.5pc increase in GDP would mean in real terms. Pakistan’s GDP is around $400 billion; 5pc to 6.5pc of this figure would be $20bn to $ 26bn, equivalent to Rs5,600bn to Rs7,280bn. To bring in perspective, the total health expenditure of Pakistan, which means government health expenditure plus what people spend out of their pocket, is equal to approximately $11bn (Rs2,000bn). So, the level of corruption in Pakistan is 2.5 times more than the total health expenditure in the country. If through a magic wand all this corruption could be stopped and the amount saved spent on health, government spending on health could be increased almost five times, since the government health expenditure is around 1pc of GDP. Ah! If only wishes were horses!

Without understanding the macro, the micro cannot be fixed.

Another way of understanding 5pc to 6.5pc of GDP is that it is equivalent to 30pc of Pakistan’s annual budget, 65pc of the value of our exports and 60pc of our total remittances. And, by the way, the IMF assesses the scale of corruption at only the federal level. Imagine if the figures from the provinces were to be added!

The government’s role in the economy, weak checks and balances on the bureaucracy, serious issues of capacity, the “interplay of political patronage and public policymaking” and “concerns over vulnerabilities to corruption of judicial institutions” are serious underlying issues of governance in Pakistan, which erode investors’ (foreign and local) confidence and diminish public trust in the system.

At the end of the day, the cumulative effect of these factors is that “citizens are regularly required to pay officials for access to services”. And at a “higher level, official policies and practices have been shaped by economic and political elites to make use of public authority to enrich themselves at the cost of greater societal well-being and economic growth”. State capture takes place through politics which eases the unchecked elite capture of the economy.

The nature of corruption is also evident from the report’s 15 recommendations. Governance-related recommendations that constrain private sector development include improvement in public procurement contracts; transparency in the SIFC; streamlining SECP regulations; digitising regulations; and accelerating the resolution of the backlog of economic disputes lying in the courts. Recommendations related to governance weaknesses that act as barriers to fulfilling public sector functions involve: rationalising and simplifying the taxation system; strengthening the FBR; improving the budgeting process; enhancing PSDP efficiency and integrating parliamentarians’ projects into the PSDP process; and developing action plans for the top 10 federal agencies with corruption vulnerabilities.

Lastly, there are four recommendations for addressing governance weaknesses that directly reduce accountability/ oversight. These include: ensuring independence of the auditor general of Pakistan; enhancing the investigation and prosecution of money-laundering offences; publication of asset declarations of high-level federal civil servants; and developing a merit-based system for appointments to the key federal oversight bodies — CCP; SECP and NAB.

Readers must be asking what all this has to do with the governance of the health system. Governance weaknesses and the consequent corruption in the country is the sum total of governance problems and ongoing corruption in all sectors. No sector can be singled out and improved entirely and sustainably in isolation. All sectors are intertwined and interdependent.

Take public procurement in the health sector. Who doesn’t know of the level of corruption in public medical procurement and the low quality of medicines supplied by companies through government tenders? Public sector health managers and professionals benefit through commissions from suppliers of medical equipment and expensive machinery, pharmacies and diagnostic labs. These are open secrets of day-to-day life at public sector hospitals. And, there is hardly any regulation of these practices in the private sector.

At the macro level, health governance is marred by unclear federal and provincial functions and lack of coordination on important public health issues of national concern. There is a general lack of transparency and accountability, as in all other sectors. The issue of lack of administrative and managerial capacity cuts across the sector. There is also the issue of generalist civil servants making big technical decisions with far-reaching economic and health implications, and technical people not understanding the rules of business of government. Lack of coordination between the health and population sectors has affected both for too long and merging them has been a political issue. The list goes on and on.

As citizens of the state, health professionals or otherwise, it is imperative to understand the larger extractive political system, the issues of governance and corruption, develop a collective consciousness and take action. Without understanding the macro, the micro cannot be fixed. Before this IMF report fades away, society and citizen groups in all sectors need to read it and relate to it through their own lives and the sectors in which they work.

The writer is a former SAPM on health with ministerial status, adjunct professor of health systems and president of the Pakistan Association of Lifestyle Medicine.

Published in Dawn, December 12th, 2025