Sania Nishtar. Choked Pipes: Reforming Pakistan's Mixed Health System.
Subject: Health care reform
Health care industry
Author: Durr-e-Nayab
Pub Date: 09/22/2009
Publication: Name: Pakistan Development Review Publisher: Pakistan Institute of Development Economics Audience: Academic Format: Magazine/Journal Subject: Business, international; Social sciences Copyright: COPYRIGHT 2009 Reproduced with permission of the Publications Division, Pakistan Institute of Development Economies, Islamabad, Pakistan. ISSN: 0030-9729
Issue: Date: Autumn, 2009 Source Volume: 48 Source Issue: 3
Topic: Computer Subject: Health care industry
Accession Number: 249960128
Full Text: Sania Nishtar. Choked Pipes. Reforming Pakistan's Mixed Health System. Islamabad: Oxford University Press. 2010. Hardbound. xxiii and 311 pages. Rs 695.00.

The kind of endorsements Sania Nishtar's book, "Choked Pipes. Reforming Pakistan's Mixed Health System", has on its back-cover can make any reviewer's task an intimidating one. With a Nobel Laureate calling it a "magisterial book", it becomes a tough task to remain unbiased and judge the book on its own merits. The book definitely gives a good consolidated account of Pakistan's health system, what ails it and how it can be improved. But does the book stand up to all the praise that it has received?

Health systems around the world, be these in the developed or the developing countries, are under great stress. Even in the last US elections, healthcare reform was a major issue, and it would not be wrong to say that Obama's health plan was a major factor in his win. Thus, it is not an issue afflicting countries like Pakistan alone. The need to reform the health system is being felt everywhere. The list of concerns in this regard can be categorised into problems of inadequate access, high cost of healthcare and the dubious quality of the services provided.

'Health system' is an all encompassing term, including in it the institutions, personnel, commodities, information, financing and governance strategies that support the delivery of disease prevention and treatment services. Worldwide, a number of healthcare reforms have been proposed, varying in nature and premise. Some suggest a quick-fix financing remedy within the existing system, without dealing with the system's inherent inadequacies; while others argue for abandoning the entire system or parts of it, and building a new one from scratch. The consensus everywhere, as in Pakistan, is that something needs to be done, but consensus has yet to evolve on what should be done.

Choked Pipes looks into all these aspects of health system in Pakistan and reflects on the multitude of problems faced by it. Starting with giving a narrative on Pakistan's existing mixed health system, Nishtar gives an account of the country's health governance, health financing, service and product delivery and health-related human resources. The book then discusses the use of technology and devising a health-information system in the country. The book ends on a detailed account of the reforms recommended for the health sector in Pakistan, within and outside the realm of health, and how such reforms should be phased.

The book can be a good source of information for anyone who wants to know the functioning, or lack of it, of the health system in Pakistan. A detailed description is given on the patterns of collusion and corruption prevalent in the health system at different levels, including hospitals, the drug and pharmaceutical sector, and in the field delivery of medical services. "The malpractices, including staff absenteeism, dual job-holding and theft of supplies", Nishtar believes are common in both the public and the private sector and need to be addressed immediately if any improvement is intended. There are stories of corruption that we hear every day and are not confined to the health sector alone, and have almost become the way of life in Pakistan. The book looks into the six decades of rot in the health system of the country as it went through one regime to another, and gives an account of how the state tried to find quick-fix solutions to the problem without focussing on the root causes. Credit, however, should be given to the author that instead of finger pointing she maintains her focus on the issues related to the improvement in the health system, and very rightly acknowledges that it is dependent on the "effectiveness of overall governance and political stability", and "overall transparency in state government".

Nishtar stresses the need for improving the welfare and social sector systems in the country, and believes that, "in the midst of many threats by and to a society deeply divided on religious and ethnic grounds, the delivery of equitable welfare services is the only tool to protect the rapidly burgeoning and impoverished base of the population pyramid from being exploited by extremist elements". No one can deny the need to make improvements in the welfare and social sectors but such statements reflect the outdated stereotype, linking extremism with poverty and deprivation. Such an idea is entirely out of sync with reality. The author seems to have fallen for this stereotype while in reality extremism very clearly is an issue that is not confined to those afflicted by poverty or lack of education or awareness. The new breed of "extremist elements" is as likely to come from an educated, affluent and urban background as from an illiterate, impoverished and rural/tribal one. Such a simplistic solution, as much as to call it the "'only tool", seems out of place in a book of this calibre.

The last three chapters of the book deal with the health reforms in the country. The proposed 'Reform Agenda' outlines four areas for reform and suggests the phases in which they should be implemented. According to the author, Step 1 should be "developing a national consensus on the reform agenda and increasing public financing for health". Step 2 should revolve around "bracing the health information system and pulling a thread through existing evidence". This should be followed by Step 3, which should have three elements--"strengthening institutional capacity; honing norms and standards, and mainstreaming the use of technology in the health system". Step 4 should be "dedicated to implementing appropriate changes in existing pilots and prototyping in key settings to develop best practices models", and lastly, in Step 5, "up-scaling of prototypes" should be facilitated. An admirable agenda indeed, but is it a practical and applicable one or is just a wish list? Most of these things have been said and written about countless times but it is the implementation that is the hard part. There are a myriad of enmeshed problems, including those related to the fiscal constraints, high population growth, low literacy levels and poor governance, that are not as easy to be taken care of m real life as they are on paper to implement.

Many readers can have reservations on the sequence of the recommended 'steps' as well. Having "increasing public financing for health" as step one and "strengthening institutional capacity" as step three makes little sense. Efficient and functioning 'pipes' of the state are basically its institutional structure. Just as there is no cold or hot water when the pipes are choked, likewise when the state institutions are dysfunctional the system cannot deliver, no matter how much public financing is enhanced. In fact, it can only aggravate the problem. Weak institutions, just like leaking or choked 'pipes', can only result in pilferage of funds and blocking of benefits reaching the intended populace. Thus, strengthening of institutions should come before the other 'steps' prescribed by Nishtar to improve the health system.

Another issue that leaves the reader a little discontented is the lack of discourse on how the current state of the country's demographic and epidemiological transitions affect its health system, and the implications of these transitions for any reforms that are recommended. Although still a young population, Pakistan has a fast increasing number of the elderly, requiring specialised geriatric care. Given the financial constraints, how should the health system deal with the very different health issues at the two ends of the population age pyramid? Likewise, an analysis of the epidemiological transition of the country shows that the disease pattern has entered the next stage of the transition without completely moving out of the previous one. Infectious diseases are still prevalent, and are now coupled by degenerative ailments, thus, doubling the burden on the country's health system. What kind of health reforms can handle this scenario for both disease prevention and cure? There is vast literature available on the topic that seems to have eluded the author.

The book seems to suffer at places from lapses in editing and inaccuracies in referencing. Some of the tables included in the book lack clarity while some figures seem to have missing information--something that you do not expect from a publication by the Oxford University Press. For instance, Table 8, on page 90, is incomprehensible even after reading the text referring to it. One is unable to make out the actual total amount given by any of the donors to the health sector, the number of years, this contribution was made and the year in which it was given because of the very crude way of computing and presenting the data. Similarly, a publication by the Pakistan Institute of Development Economics (not 'Developmental' as mentioned in the reference number 199, page 267) is wrongly cited as "Working Paper 4". The said publication was a report not a working paper by the Institute.

Despite these shortcomings, Choked Pipes' does make a compelling read. And going back to the question raised in the beginning, "does the book stand up to all the praise it has received?", one is inclined to answer with a yes and a no--the yes being slightly bigger than the no. It can be a very useful reference book for those trying to understand the health system of Pakistan but the recommended 'reform agenda' needs more critical thinking. Health being a complex multidimensional issue, as stressed by Nishtar as well, cannot be reformed by ideas that have been repeated endless times to date. A new value system is needed to govern the health system, as an analyst once stated, "There is no way to adjudicate disputes between the Holy Trinity of cost, quality, and access unless a court of values is available to dispense its wisdom". Thus, a new approach is needed--one that is pragmatic and covers all dimensions including, medicine, ethics, law, public health, insurance and population dynamics. Credit is, however, due to Sania Nishtar for providing a timely warning to initiate steps to unclog the pipes before it is too late, and Choked Pipes could be considered making a major contribution if it puts the health agenda back on the discussion table of the policy-makers.


Pakistan Institute of Development Economics, Islamabad.
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