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Healing the healer

September 03, 2012


Two recent changes have transformed the context of health care delivery in Pakistan - for the worst. The combined effect of 18th Amendment of the Constitution and the suspension of the Local Government Ordinance, one after the other, in 2010 brought a domino effect on the service delivery system. Though there is still distance to cover towards total transfer of powers from the federal as well as the local levels to the provincial governments, those responsible to run the system seem totally bewildered and unable to cope with the tremendous challenges as enunciated in the so-called Millennium Development Goals in health targets.

At the heart of this conundrum is the fact that, whether federal, provincial or local governments were responsible, a miserly 2 per cent of GDP is spent on health – much lower than other countries with similar income levels. The government contributes only a third of this 2 per cent and the remaining two third is paid out-of-pocket by consumers at the point of service delivery.

With such allocations, no wonder our health providers in the public or private sector are poorly trained, lack motivation and are distracted from their work by conflicting interests. Weak governance, lack of equitable service delivery, absence of social safety nets, lack of effective implementation of regulations particularly in a large unregulated private sector are having adverse impact on the performance of the health sector.

But that’s not what this blog is really about. This blog is about the fact that though failure of the health system is a common, everyday experience, and corruption is seen to be endemic to the sector, there is little public outcry. This blog is about effective mechanisms of public and private providers’ accountability by the citizen consumer.

With public funds, as well as aid transfers to health sector set to increase in the future, it is absolutely critical that public sector service consumers demanded greater ‘value for money’ and be willing to organise themselves for carrying out scrutiny of public health expenditures, more effective policy and planning, and improved oversight.

Many of the public institutions that should be contributing towards transparency and accountability in the health sector in Pakistan are themselves victims of the systemic deficiencies they seek to address, such as political patronage and corruption.

The way accountability of the public sector by the citizen consumer is known to work elsewhere in the world is that concerned citizens join hands with the media and work towards growing a public demand for responsive, accountable health services. The demand should focus on a framework whereby public planning, reporting and monitoring systems were opened for accountability by the consumers’ fora.

An important element of this accountability is to establish legal and regulatory mechanisms and making them available to consumers in order for them to undertake regulation of public, private and alternative health sector.

I understand that firm grounds for effective public communications and advocacy on health exist today due to the growth and openness in the media which is widely recognised as a positive driver for change in Pakistani society. The Media is already increasingly seen taking a proactive role in public interest and is well poised for contributing in generating the necessary political will for change.

A strategic alliance between organised consumer resource groups, think tanks and the media would be needed to generate compelling and evidence-based narratives on health for the media. To add to the demand side initiatives, community-based organisations can be encouraged to voice demands for local level public, as well as private service providers to produce more responsive health services.

Access to information regarding health services and expenditures is the cornerstone to accountability in the provision of services. While a lot of work has been done to make the public sector information available to citizens, there hasn’t been much experience in the health sector. Increased public scrutiny of health services can be reinforced by local level public and private sector services information collected by community based organisations. This is a critical area for exploring further as the capability of the public health system to respond to the needs and demands of citizens is the lynchpin of an accountable health sector.

Having spent many years with a consumer protection organisation of Pakistan, and traveled to many places around the world in this connection, my considered view is that civil society organisations have a pivotal role to play in making services responsive and accountable by undertaking advocacy at local, national and international levels in support of improved service provision.

There is a lot of evidence to support this view from within Pakistan, as well as around the world to show successful outcomes of citizen’s voices demanding system reforms in decision-making, authority over facilities and budgets, good information and monitoring systems, and an availability of mechanism of redress.

Important factors of success in making health systems responsive and accountable by the consumer citizen would include remaining sensitive to local context and raising well-informed ‘voices’.


Ayyaz Kiani is a public health specialist. He heads Devnet – a network of development consultants. Based in Islamabad, he has travelled around the world and continues to do so to meet fellow travelers. He can be contacted at


The views expressed by this blogger and in the following reader comments do not necessarily reflect the views and policies of the Dawn Media Group.