Politics of health

Covid-19 has exposed a global failure in public health, and Pakistan is no exception. It has consistently allocated insufficient federal and provincial budgets to support basic health services for its growing population.

In the public discourse, the limitations of our Covid-19 response are rightly being attributed to a culture of chronic underinvestment, poor infrastructure (the hardware) and weak capabilities (the software). It is also (although less often) being attributed to behavioural and social barriers that continue to hinder our response to the crisis.

All these are undoubtedly contributing factors. However, what we often fail to recognise is that before anything else, the reason why we are where we are is first and foremost due to political economy challenges. And unless we understand and tackle these core issues, sustainable change is unattainable. In other words, it is important to tackle the problem behind the problem.

Let us begin by understanding the core political economy factors that have traditionally hindered progress in the health sector. A big driver is the fact that Pakistan has consistently experienced low level of state-citizen accountability on health. There are weak links between how our governments serve us on the health agenda and our voting decisions. Politicians understand that and therefore spending funds and attention on this issue is not their priority. In other words, there are no societal pressures on our leadership to achieve health goals. It is as much on us as voters as them.

Having said that, Covid-19 has generated a temporary momentum whereby both the political palpability of health agenda has grown as has the societal pressure. We have seen that not just the health ministers, but the wider political economy players, have paid unprecedented attention to the health sector. This includes government, opposition and other formal and informal influential players of the societal structures.

We have also witnessed a sense of political competition between provinces on the coverage, quality and pace of the health response. These developments signal that pockets of pro-health reform have emerged at the federal and provincial levels. If we look deeper, these pockets are a combination of driven bureaucrats coupled with supporting ministers at national and sub-national levels.

Similarly, the traditional culture of limited accountability of the state on health outcomes has also recently been (at least partially) challenged. Since the wealthy and influential groups couldn’t isolate themselves from the Covid-19 health risks, the space for societal pressure has strengthened with support from new corners of society with expectations from the government. However, what is important is that we make conscious effort to use these shifts, which for now seem temporal, to lead us to potentially transformative shifts. But are there any governance entry points that could be prioritized to attempt sustaining the change we see emerging through Covid-19?

I believe that there are three core governance issues in the health sector that Pakistan should try to push for to translate the current political attention into meaningful long-term changes. First, the government needs to revisit its responsibilities on health and focus more on regulating the market than providing direct service delivery. Currently, roughly 65 percent of the health services in Pakistan are provided through the private sector and the remaining disproportionate amount of direct service delivery is done by the government itself.

This is not efficient. It consistently provides opportunities to vested interests that hijack the health agenda as the state machinery gets consumed by the misuse of public health jobs for electoral gains. The health ministries are busy spending a disproportionately high percentage of time on staff postings, transfers and labor association issues. It loses focus on its core function which should be to regulate this market, manage affordability, access and coverage through a strong policy direction that builds on the principles of public-private partnership.

Pakistan should consider treating the health sector as a market and whilst government should intervene where market failures exist, it shouldn’t be intervening at the scale that it currently does.

Second, just as education is explicitly stated as fundamental right under the constitution (Article 25A), so should be health. This allows for better opportunities to reform the sector and push for initiatives like universal health coverage. Third, we need to push for more clarity on what the 18th Amendment devolution means for the sector in terms of roles and responsibilities between federal and provincial structures. This issue isn’t unique to the health sector; we need to know who was expected to do what under Covid-19 since the blame game was in the public eye, and there is more appetite to clarify roles.

To sum it up, the opportunity to capitalize on potential political economy openings relies as much on the political leadership as on the civil society to keep expecting from their elected representatives. The media should continue to provide evidence-driven performance reporting on the federal and provincial governments’ response to the health crisis. Doing so will strengthen incentives for political leaders to continue to priorities health reforms and engagement. Society needs to signal the connection between the performance of the different provincial governments to the health and interlinked socio-economic crisis through featuring this in their electoral decisions. Therefore, this momentum needs to be sustained and used effectively at the time of next elections.

There is no doubt that Pakistan is a resilient nation, but it is important that we don’t let a crisis go to waste, and use it to raise the bar on health for our future generations to come. The journey to get us there is not just technical but political – and political is not just the government, it is also us as voters. We should demand more.

The writer is a public policyanalyst based in Islamabad.

Twitter: @sanazia