WE must state at the outset that we have been wary of, if not actually opposed to, the prospect of further economic assistance to Pakistan because of the callous misuse and abuse of aid that has marked the past across all elected and non-elected regimes.

We are convinced that such aid, driven by political imperatives and deliberately blind to the well-recognised holes in the system, has been a disservice to the Pakistani people by destroying all incentives for self-reliance, good governance and accountability to either the ultimate donors or recipients.

Even without the holes in the system the kind of aid flows being proposed are likely to prove problematic. Over half a century ago, Jane Jacobs, in a brilliant chapter (Gradual and Cataclysmic Money) in a brilliant book (The Death and Life of Great American Cities), showed convincingly how 'cataclysmic' money (money that arrives in huge amounts in short periods of time) is a surefire way of destroying all possibilities of improvement. What is needed, she argued, is 'gradual' money in the control of the residents themselves. While Jacobs was writing in the context of aid to impoverished communities within the US, she concluded with a remarkably prescient concern “I hope we disburse foreign aid abroad more intelligently than we disburse it at home.”

Notwithstanding our misgivings, we are realistic enough to realise that the political imperatives for further aid in the form of cataclysmic money are overwhelming — the states and agencies representing the donors and recipients and the non-state contractors on both sides are desperate for the leaky plumbing to fill up again under pressure and there are those who are salivating at the thoughts of where they will find new holes to drill.

The putative beneficiaries in Pakistan and the taxpayers in the donor countries, those who should have the most to say, are the ones with the least influence on this merry-go-round of aid. Effective watchdog groups are conspicuous only by their absence.

In the light of this realisation and the progress of the Kerry-Lugar bill, we had circulated a note to donor agencies, think tanks, and congressional committees last year on how to ensure that new money does the least harm, and at least some good, to the health and education sectors in Pakistan. We are reassured to see that the central ideas are also reflected in the Signature Health Programme announced this month during the most recent visit of the US secretary of state to Pakistan.

While this programme adopts the right approach, that of concentrating resources on the revitalisation of key facilities rather than spreading them thinly across countrywide initiatives, we feel the need to spell out for public discussion the vision, its rationale and the set of complementary activities that are essential to making these investments both sustainable and catalytic for the sector as a whole.

The central premise of our recommendation is that the gaps in rural healthcare are too large to be fixed in the short term while a focus on tertiary care is of limited benefit to the majority of the population. The district hospital forms the heart of the healthcare system in Pakistan. The weak rural health cover pushes all patients with even the slightest complication to the district hospitals overwhelming their limited capacities and making them visible symbols of system failure.

In turn, the district hospitals are unable to fulfil their role as filters for the tertiary-care facilities in the metropolitan centres. Only a major upgrade of the district hospitals would provide immediate relief to the health system while triggering the backward and forward changes that would deepen the reform process. This is the only intervention with the potential to unleash a new dynamic in the short to medium term.

The essential pre-requisite to using aid effectively is to use it to structure the change dynamic around a small number of discrete interventions that have very high impact, are easily manageable, need minimal involvement of the local bureaucracy for initiation, can be monitored by citizen watchdog groups, and can deliver immediate and visible benefits to marginalised groups in society. The limited number of district hospitals in the country makes this choice the optimal one in the circumstances.

In order to make these investments sustainable and catalytic it would be important to identify and put in place the upstream and downstream linkages and the complementary reforms necessary for the efficient functioning of a district hospital as the focal point of a national healthcare system. A focus on facilities alone would cause the initiative to wither soon after the funding ends. These complementary reforms would include aspects of governance, regulation, accreditation, staffing, compensation, vocational training, procurement, etc. The district hospital should be the nucleus for micro experiments in the systemic reform without which any sector-specific change initiative would flounder.

What we have not been able to stress to individual donor agencies but consider of overriding importance is the recognition by Pakistani policymakers that it should be the Pakistani state and not piecemeal programmes of donors that should be ultimately responsible for a coherent long-term vision for the sector. Donor investments have to fit into and not drive the sector strategy.

Given the limited capacity of the state, one of the most effective measures to ensure efficient and coherent utilisation of assistance would be to implement this sector strategy in a competitive format. For example, in the first iteration, the rehabilitation and management of five district hospitals each could be assigned to different bilateral donors in competition with each other and with the local public sector as well.

The injection of a competitive dynamic would itself generate incentives for good performance that have been conspicuous by their absence to date. In addition, this format would also facilitate local experimentation with different practices in order to identify what might work best in the specific context of the country. This was the model underlying the emergence of the globally recognised stature and performance of the Indian Institutes of Technology.

Such an initiative would need to be supplemented by a plan detailing how and over what time frame the revitalised asset base would be fully integrated into the national healthcare system. This would require identifying capacity-building needs, administrative reforms, and the modalities of continued citizen involvement needed to ensure the sustainable operation of refurbished assets. Aid need not be destructive if it is designed intelligently by the host government, implemented transparently by the contractors with public disclosure of budgets and milestones, and monitored rigorously by the representatives of taxpayers in the donor countries and of end users in Pakistan.

Samia Altaf is a public health physician; Anjum Altaf is an economist.