The root cause

By Dr M. Javaid Khan

In the 1800s, the British army was confronted with machine gun for the first time. At that time, British battle strategy was to have the soldiers — who wore brightly coloured uniforms — present a united front by marching forward toward the enemy in long, straight rows. This had been effective in times past, for the approach of many rows of highly visible soldiers was intimidating to the enemy. However, in their initial confrontation with these machine guns, 500 British soldiers were killed immediately. When the British field commander saw the devastation, he sent the communication back to headquarters: “Send me 500 more men!”

What was the wisdom of sending another 500 men to their deaths by using the same strategy that had cost others their lives? And this is exactly what Dr Sania Nishtar has endeavoured to tell in her book Choked Pipes. Nothing could have portrayed better the universal truth that stagnancy leads to ruin, than the title of the book describing the poor health system of Pakistan. A timely forewarning to start taking steps for cleansing the clogged pipes, as today many are still trying to solve tomorrow’s problems with yesterday’s solutions, and it’s not working and will not work.

Exploring such clogged pipes and putting the picture on the table was really a gigantic task that an author could undertake. Practising “heart medicine” until a few years back the author is now contributing to health system development by diagnosing and prescribing for the ailing heart of social sciences — Public health.

Universal healthcare access has bedeviled, eluded, or defeated every government for the last 63 years. There had been fragmented efforts that too personality dependant but never a comprehensive approach ever adopted. Different governments toyed with different ideas, including hospital autonomy and health insurance that subsequent governments never heeded to.

This timely book puts the present government fresh quest for a new health policy in historical perspective and gives new meaning to hope. With meaningful cover page the book has a treasure of information on Pakistan’s health system. A major contribution to the public health policy domain, the book would unquestionably initiate discussions and dialogue and shape the public debate over it.

One of the many strengths of the book is its multi-sector health system approach arguing for a paradigm shift in thinking and evolution of a healthcare system in true spirit, rather than the continuation of current ‘sick care system’. Author’s call for developing a national consensus around a reform agenda is also very timely as different provinces, in view of recent increase in provincial fiscal space courtesy new NFC award, are contemplating reforms; comprehensive development strategy of Khyber-Pakhtunkhwa was an example.

She touches very elaborately on primary to tertiary healthcare. She argues with the enormously available current evidence for hospitals restructuring arrangements, strategic purchasing and Public Private Partnership for harnessing the outreach potential of private providers.

The directions for reform stated in the book present a logical separation of areas within which detailed planning now needs to be structured to outline the specifics of the nuts-and-bolts of how these directions will cascade into implementation. In particular, the variegated approach to social protection deserves special attention. By alluding to the different modalities applicable to the informal and formally employers sectors with regard to financial risk-protection, a whole new dimension in planning has been alluded to. Sector experts must now get a consensus on how to institutionalise this approach in Pakistan’s complex and fragmented health system.

In addition, to policy makers, students of public health, other social sciences and even medical professional will profit from the book. Figures, tables, charts in the book are attractive, simple, and conveying message at a glance. Those who do not have time to read the book in full should at least go through Table 14: Reform Agenda — a snapshot, on page 246 that describes concisely the gist of various themes/ideas.

Dr Sania’s book is a major contribution to health system strengthening efforts in Pakistan, regionally and internationally. Her efforts in identifying the issues and recommended options must be considered deservedly and implemented if Pakistan is to stand as a responsible nation.