In 2013, the health section of five major political parties’ manifestoes – Pakistan Muslim League (Nawaz), Pakistan People’s Party Parliamentarians, Pakistan Tehreek-e-Insaf, Mutahida Quami Movement, and Jamaat-e-Islami Pakistan – focused more on strengthening health system hardware – upgrading of district and sub-district hospitals, deployment of mobile health units, addition of human resources for health in rural areas, establishment of food and drugs testing laboratories, launching of health insurance programs, and enhancing the coverage of service delivery programs. Similarly, the developments projected on the websites of departments of health run by the Federal government, and the Punjab, Sindh, Khyber Pakhtunkhwa, and Balochistan provincial governments and the grey literature published during the last 5 years clearly show a tilt towards the addition of hardware into the system. A snapshot thematic analysis of the speeches made by the ministers of health in public meetings over the last year also signals a very strong focus on the hardware.

The decision to prioritize hardware over software makes sense both from electoral politics and technical perspectives. Since hardware is very visible, can be easily showcased to point out achievements, and can improve the public image in a relatively short time, politicians’ fondness to prioritize it can be easily understood. Pakistan is certainly no exception to this rule. Moreover, the country’s health system certainly needs immense public investments into the hardware, as the ratios of health workers, hospital beds, and outpatient facilities per 10,000 population, and governmental spending on health are substantially lower than the corresponding average values for other lower middle-income countries.

Nevertheless, prioritizing health systems hardware over health system software raises a few questions. Is not software needed, such as placing public health goals above private self-interest, transparency in procurement procedures, community participation and empowerment, crediting and striving for equity, intra and inter-sectoral coordination, awareness of power dynamics, sensitization of each stakeholder’s own legitimacy, role and practice in the system, relevant legislations and regulations, required knowledge and skillset? If all these are needed, why have these important software issues not been on the political agenda so far?

Let’s focus on corruption by way of example. Pakistan has been ranked consistently low in its public-sector governance and combatting corruption would be one type of policy to improve health systems software. According to the corruption perception index 2017, the country is ranked 117 out of 180 countries in a global ranking – not exactly an enviable position. There has been no recent comprehensive country level assessment for the health sector. The latest statistics published in 2006 revealed, however, that 95% of the population perceived high levels of corruption in the health sector and 96% of the users who sought services from public health care providers made informal payments. The reported underlying reasons for corruption in the health sector were the lack of explicit performance standards for providers, collusion in contracting, lax fiscal controls in public funds management, limited enforcement of rules and no sanctions, lack of accountability and oversight, and limited citizen involvement – most of which are related to health system software. Chances are not much has changed since 2006. In a country where domestic general government health expenditure makes up just 1% of its GDP, the significance of plugging corruption-related leaks is undeniable. From politicians to patients, “the abuse of entrusted power for private gain” needs to dealt with, not only in Pakistan by the way but globally, as corruption in healthcare is rife worldwide, according to a 2016 report.

For politicians, potential reasons for not prioritizing changes in health system software in a typical lower middle-income country context could be that such reforms require consistency, long-term commitment, are not readily visible, and sometimes threaten the interests of powerful constituencies (like political partners, bureaucrats, pharmaceutical companies, etc.), which may not always be politically feasible. While development partners have been increasingly focusing on improving governance and combatting corruption, their work has often been more normative. Less support has been offered to countries on the “how”, when it comes to dealing with corruption. In addition, civil servants, who usually get promotions based on their political loyalties rather than merit, often prefer aligning their work with short term political goals rather than setting the house in order (some would say ‘on fire’). Traditionally, with more funding options available for disease specific responses, strengthening the institutions has also not been high on civil society’s agenda. Further, there have been very limited tracer indicators developed for assessing cross-country and within country performance on the health system software situation.

Concerted efforts will be needed to ensure that the policy agenda combines the health system hardware with the required software. The forthcoming manifesto review meetings organized by political parties will be a good platform to highlight this need. Otherwise, the hardware added into the system may be used more for political mileage rather than health system strengthening.

Disclaimer: Views expressed in this article are those of the author and do not represent his official position

Against this backdrop, the three largest political parties in the country announced health insurance programs, particularly for the poor, as part of their election platforms in 2013. Prime Minister Nawaz Sharif, in keeping with his party’s electoral campaign promises, launched a National Health Insurance Program in 2014. The program has enrolled 1.06 million below poverty line families in 16 districts of four provinces so far and will likely be extended to more than 50 districts across the country before the next elections in 2018.

In 2015 one of the main opposition parties, in keeping to its campaign promise, also started a provincial health insurance scheme in Khyber Pakhtunkhwa province, where it holds power. The scheme has enrolled 1.16 million households in 25 districts so far and has plans of enrolling everybody below the poverty line in the province before it goes into the next election cycle. Gilgit Baltistan province has also started its social health protection program.

With this brief context, one gets a sense of the current (increasing) political focus on social health protection reforms in the country. However, if the locally relevant evidence made available to policy makers for planning, implementing, and monitoring of the ongoing programs in the last four years is tracked, it will be difficult to find even a handful well-thought commentaries, reports, op-eds, and blogs – let alone peer reviewed publications on such large-scale reforms in the country. This signals a disconnect between health systems and policy research and political priorities in Pakistan.

In this blog, I will suggest three broad areas to strengthen the institutional arrangements for generating the required evidence for the ongoing social health protection reforms in Pakistan. For all three areas, I’ll list a number of recommendations.

First, there is a need to outline the type of evidence needed.

A baseline mapping of the current Universal Health Coverage (UHC) status at the provincial level is needed. Building on this, the impact of the recently launched programs on both dimensions of UHC should be tracked at the sub-national level.

Also, for priority setting, health technology assessments are required to decide what goes into the benefit package. There is also a need to periodically review the targeting registry (list of below poverty families) and provider payment mechanisms.

In addition, sustainability of these programs (fully subsidized as of now) should be accessed through longitudinal fiscal space analysis and budgetary projections (together with the ministries of Finance – both at the federal and provincial levels).

For equity analysis, benefit incidence analysis of current public spending and assessment of the burden of diseases is necessary, especially when they are due to non-communicable illnesses.

From a governance perspective, enablers and barriers for the two types of partnerships (federal-provincial and public-private) established in these programs and limitations in public financial management should be investigated to smoothen the planned scale up.

Secondly, individuals and institutions involved in the generation of health financing evidence, the stakeholders, and the knowledge brokers should be identified.

The Pakistan Bureau of Statistics has a good foundation for health expenditure tracking, through Household Integrated Economic Surveys and National Health Accounts. Schools of public health (14 of them across the country) have an immense opportunity of translating the wealth of operational data being generated by the health insurance programs into impactful knowledge products through implementation research. The Pakistan Institute of Development Economics along with health economics departments in schools of public health should take the lead in laying down the groundwork for health technology assessments.

The recently established Health and Population Think Tank at the Ministry of National Health Services Regulation and Coordination can be an effective knowledge broker at the critical junctures of policymaking, for example when changes in benefit package and provider payment mechanisms happen. Civil society organizations can play an important role in developing the demand for evidence-based policymaking and advocating for legal frameworks that require evidence review for policy change.

Lastly, concerted efforts are required by institutions and individuals to develop and sustain capacities for knowledge generation and translation, and let the evidence feed the health financing policymaking process.

It is important that policymakers and practitioners understand that there is no blueprint for social health protection reforms and that locally generated, reliable, low cost and regular evidence will be pivotal for their successful rollout.

Provincial governments, development partners and donors should invest in developing organizational capacity for analysis at the provincial level, rather than focus on short term consultancies.

A critical mass of health financing researchers should be built by sponsoring Masters and PhD dissertations/implementation research on the current reforms.  Also, provincial health accounts’ capacity should be strengthened for regularly generating health financing expenditure information at the provincial level.

Think tanks could help establish mechanisms for regular engagement of analysts and researchers in the policymaking process. Individual researchers need to make their work “policy relevant” and maintain long term relationships with decision makers. They should summarize and interpret their findings for policy relevance.

Although evidence will not be the only ingredient in Pakistan’s health financing policy recipe and good quality evidence might be ignored, resisted, and used selectively (as is the case anywhere in the world), in the long term, the impact of good quality evidence is bound to be positive. But for this to happen, appropriate institutional arrangements need to be in place.

Declaration of conflict of interest: I have no competing interests

“We lost an exemplary son, a respectful son-in law, a loving father, a caring husband, a kind brother, a sympathetic relative, a helping neighbor…” were the phrases passed by the dearest of Asmat Malik, who laid him in his grave with sobbing eyes on May 30, midnight. I was among hundreds of Asmat’s friends attending his funeral in Attock, Pakistan. People had travelled hundreds of miles, while fasting on a long hot summer day, on a very short notice for the funeral prayers. It seemed so difficult and painful for many to come to terms with the reality. With an immense sense of loss, I witnessed his professional colleagues remembering him as bright, humble, intelligent, well-humored and a “Rising public health star of Pakistan”. Each of them had wonderful memories to share. Soon after I had left the funeral, I saw more than 150 heartfelt condolence messages sent via email/WhatsApp from Asmat’s friends in more than 30 countries to me to be forwarded to his family. Inevitably, these messages were laden with great sadness, shock and surprise, but they were also full of Asmat’s qualities, fond memories and sincere wishes for his family.

For those who interacted with Asmat briefly and know him just as a helping hand, let me quickly recap his professional life here. Asmat was a medical doctor and a systems analyst by training with a PhD in Health Policy and Systems from the University of Queensland. He worked over 18 years in health systems of South-East Asia and Africa, and was an international expert and a trainer on developing Comprehensive Multi-Year Plans (CMYP) for Immunization Systems. He had great skills and expertise in developing health system strengthening initiatives in resource limited settings and had successfully developed GAVI Health System Strengthening Grant Applications. Besides working in Pakistan, he had developed strong collaborations with internationally recognized institutions, including The University of Queensland (Australia), ITM (Belgium) and the Alliance for Health Policy and Systems Research (Switzerland).

Being an active member of the Emerging Voices for Global Health (EV4GH) Program since 2010, he had developed strong professional ties with emerging health systems researchers and policy analysts from more than 30 countries in the Global South. Since 2015, he was also co-chair of the EV4GH governance team.  More in general, he’s been a companion of the EV4GH programme from the very start in Montreux and has mentored various EV cohorts over the years, with great skill. Many EV alumni still can’t believe the venture will now have to go on without him.

Those who knew Asmat personally, considered him a role model for work-life balance – one of his many qualities. He was skillful in managing time, stress, change, and leisure. His down to earth attitude & cheeky sense of humor certainly helped in that respect. Many of us looked up to him. And none of us feel ready to use the past tense when thinking about Asmat.

Asmat fought a brave battle against end-stage liver cancer in the last two months of his life, with the support of Neelofur, Sabeeha, and Haseeb – Asmat’s wife, daughter, and son. Neelofur is a practicing gynecologist in Attock, Sabeeha is taking her A levels exams and Haseeb is an O levels student.  God bless them at this time of extreme sorrow.

Grief can be so hard, but our special memories help us cope. I request all the friends to share their special experiences (personal or professional) with Asmat in the comments below. Sabeeha and Haseeb will likely feel prouder and draw inspiration from enriching experiences of their accomplished father!

“Health systems research is about problem solving and skills that enable innovation and creativity, which are not the purview of a single discipline or topic; therefore, young professionals should persevere and gain the knowledge and expertise that excites them – and then learn to apply them in real world settings. It is ok to be bold and try new things – it is ok to persist and explore – but it is not ok to accept the systemic inequities and social injustice in this world.” Adnan Ali Hyder, Professor at Johns Hopkins Bloomberg School of Public Health

“First, don’t be afraid to be different, but respect viewpoints that differ from yours. We are a diverse community, have different histories and viewpoints. Without further dialogue, we can’t keep learning and constructively engaging with the complex, nuanced and contextual nature of health systems we care about. Second, nurture relationships, they will evolve overtime and anchor you in ways that are currently unforeseen. We are a nascent community, one with its own inequalities and frustrations. We need to work harder with a longer-term vision of realizing just health systems and societies and not get consumed in short term tactics guarding false boundaries and dominions. Third, don’t wait for funding or approval to pursue what is important. Funding can be insecure and fickle; institutional norms that define advancement maybe not always be fair or relevant. Be mindful of the compromises made and safeguard what you value. Our field needs critical thinking, credibility, creativity and passion to sustain the unpredictable, messy, political worlds we have to navigate.” Asha George, Vice-Chair of Health Systems Global

“Make the most of any opportunity that comes your way; focus on doing it to the best of your ability, and other opportunities will come.” Anne Mills, Professor at London School of Hygiene and Tropical Medicine

“Health systems research is often inter-disciplinary and collaborative, involving teams of researchers with complementary areas of expertise. If you can, choose research topics that are not just important and policy relevant, but that excite you and keep you motivated.  Become an expert on previous research on your topics of interest – and consider developing a research agenda to help guide you on what opportunities to pursue and the role you want to play in research teams.  Also, be on the lookout for surprising, counter-intuitive findings – these are often the most interesting!”
David Hotchkiss, Professor at Tulane School of Public Health and Tropical Medicine

“As health policies and programs “mature”, there is a tendency for policymakers and implementers to accept their gaps and problems partly because changing “mature” policies is seen as too hard and there are minimal incentives for them to do so – just as it was before in other sectors such as the telecommunications and the transport sectors – and just as these sectors were challenged and then transformed by, among others, young research-driven innovative people who challenged the accepted thinking, young health researchers such as the Emerging Voices  should similarly intensively study and challenge, if necessary, and propose innovative and disruptive, if needed, actions and transformations for Universal Health Coverage.” Eduardo Banzon, Principal Health Specialist at Asian Development Bank

“Young health system researchers should conduct impactful research and use knowledge translation tools to impact policy and practice. They should produce research that is connected to real world health systems and priorities and that is grounded in the practical understanding of political contexts and constraints. They have a role not only to respond to policymakers’ priorities but also advocate to shape policy agendas and influence action. They should support interdisciplinary collaborative research work and should also partner with policymakers and policy implementers in creating and applying new knowledge.” Fadi El-Jardali, Professor at American University of Beirut

“If one accepts that health is a human right, one can only assess the present situation of global health (and its enormous inequalities) as a massive and continued human rights violation. Young (and older) health systems researchers must find a middle ground between assuming that states will continue to behave more or less as they currently are (which leaves little room for improvement), or assuming that states will live up to their domestic and international responsibilities (which seems unlikely to happen). In this uncomfortable position, it is important to be aware that whatever solutions we recommend, they will shape the future, one way or the other.” Gorik Ooms, Professor at London School of Hygiene and Tropical Medicine (LSHTM)

“First – frame research questions in terms of what you see and experience, even if this does not match how the same issue is discussed in the literature. Health systems research is a new field and it needs new perspectives on old problems. Second – think about the many written and unwritten rules and norms of global academic practice. These don’t come from a higher power, but are/were made by people working in specific social and cultural contexts. Many rules are rooted in good sense and fairness. Others reflect convention at the expense of relevance, and deserve to be questioned. Third – challenge yourself consistently on the quality of your own outputs – as research professionals we have a responsibility to be rigorous and credible.” Kabir Sheikh, Chair of Health Systems Global

“Be persistent and develop ideas over the long-term – adopt and fight for the practice of ‘slow academic scholarship’. Build on the work that has gone before – recognize it and add to it. Recognize that health system software (values, norms, relationships, trust, power) is always important – make it the focus of future research, not just the unanticipated ‘factor that matters.” Lucy Gilson, Professor at University of Cape town and LSHTM

“My advice for young researchers in health systems is to think about the three areas of ideas, people, and writing. Try to find one good idea that changes the way health systems are understood; seek out people who can collaborate with you and expand your capacities and tell you when you are wrong; and pursue excellent writing that is clear and succinct and makes sense. These three pursuits of ideas, people, and writing will help you develop in synergistic ways; and weaknesses in one area will diminish your capacity in the other two.” Michael Reich, Professor at Harvard T.H. Chan School of Public Health

“It is very dangerous for health systems researchers to focus on building evidence that advances Resilience as an approach to comprehensive health systems strengthening without interrogating its added value. Just like the agenda on Structural Adjustment Programs advanced in the early years, Resilience could blindfold researchers as a magic bullet to addressing the current challenges of health systems. The rational is still not clear for abandoning a more comprehensive approach to health systems strengthening to now Resilience, which is also variously interpreted as evidenced in the various sessions at the conference. Resilience is very capable of turning into the new ‘conspiracy theory’ bred through the current system of dis-empowered states and the strong private sector.”
Moses Mulumba, Executive Director of Center for Health, Human Rights and Development

“Seeing young researchers emerge at the Global Health Symposium might be the best part of a very impressive event, I think. A new generation is coming through the global health community, and it has a rich contribution to make from almost every culture and every continent. It inspires me. Perhaps we could draw more on the energy created by the very best of these younger minds. There is a new generation of health researchers and policy makers now coming through and they will take the science and the practice of global health in new, exciting directions.” Peter Annear, Professor at University of Melbourne

“For young researchers and activists from the Global South, I have a triple advice: i) make sure that your research and advocacy is deeply rooted in your local or national realities; ii) make sure you know the evidence around your topic very well, and that your contribution is connected to that evidence; iii) don’t be boring (when you make your presentation, especially when it is an oral presentation).” Wim Van Damme, Professor at Institute of Tropical Medicine

Learning lessons from more experienced scholars and practitioners can certainly help us shape our ideas better.  As the saying goes: “it takes a wise man to learn from his mistakes, but even a wiser man to learn from others” (before my “Women in Global Health” EV colleagues take offense,  this certainly applies to women too!). By the way, I had aimed for a perfect gender balance while requesting the senior researchers to share their quotes, but not everyone responded, so you might have observed a bit of imbalance.

Having interacted with the Emerging Voices & young health systems researchers from more than 50 countries for a couple of weeks in Vancouver, I feel that each one of us has at least one skill and expertise we can capitalize on. Some are good on paper, others are very eloquent on the stage, still others make excellent policy brokers, at national or even global level. We need to recognize what we’re good at, and make the best use of it, to have an impact in the world around us. As you might have noticed, the world is witnessing major crises, which is why global health, even more so than in the past, has to be political. The energy of young people, including researchers from all over the world, will be needed to fend off catastrophe in the coming decades. In other words, passion is a must now. Youthful passion inspired by wisdom, let this be the motto for the new year.

2017, here we come!

Discussions at the ADB session left me with some thought-provoking questions. The session was intended to help participants develop a more informed understanding of the current direction of efforts towards achieving universal health coverage (UHC), and to share potential problems in efforts to provide health services for mobile populations. It was to think of ways in which to give a voice to different perspectives at the individual and institutional levels, and to think of creative solutions for providing health coverage and access to migrants.

The session started with the acknowledgment that to date, the UHC debate has largely focused on citizenship. Country level policymakers have been striving to cover their citizens first, before thinking of non-citizens. Indeed, in a resource-constrained setting, this would seem natural. However, in this increasingly mobile world, it is important to think about how to provide health coverage and financial protection based on where one lives, not where one comes from – to expand the UHC debate to imply ‘health for all’, not just for citizens of a country but health for all – everywhere.

Azusa Sato from the ADB outlined the migrant movement in Asia Pacific – the trends, employment and health issues faced by mobile populations, the systems and policies currently in place, and the role of ADB in addressing these issues. Two important insights were the broad approaches adopted by some sending and receiving countries in providing access to the migrant workers; the first approach termed – “UHC approach”, is relatively holistic, inclusive and does not differentiate nationals from non-nationals. The second approach called “worker and/or employer sponsored approach” requires compulsory contributions to cover the migrant employees.

Speakers and participants wrestled with various countries and regional level challenges in the first half of the session. Kenneth Ronquillo from Department of Health, Philippines shared the myriads of health risks faced by overseas Filipinos; this population comprises 16% of all the HIV/AIDS cases since 1984 in the Philippines; they face issues related to mental, sexual, reproductive, and occupational health in the destination countries; irregular and informal migrants are not able to access even basic health services. Inez Mikkelsen from ADB’s pacific regional department shared that there are small island populations with very few health centers in the pacific region, and the demand for off-island health care has outstripped the resources in the pacific region in the last few years; increasing numbers of pacific residents must obtain care off shore—in Australia, New Zealand, Philippines, or United States. Off -island health care is relatively expensive due to the additional cost of transportation and the higher cost of care.

Goran Zangana – an Emerging Voice (EV) from Iraq mentioned that due to internal conflicts and the war on terror, many geographical boundaries (borders) are irrelevant in Iraq and its surroundings; there is an overwhelming number of internally displaced populations and migrants from the neighboring countries in Iraq. He further stressed that the idea of UHC beyond borders should not be confined to migration due to work but should encompass migrations because of any reason. Deepika – an Emerging Voice from India reflected on operational challenges in holding the private sector accountable in a large-scale national level subsidized health insurance scheme for the poor in India, of which internal migrants are an important sub-population.

Possible solutions for the aforementioned challenges were discussed in the second half of the session. Gorik Ooms, now at the London school ( always a delight to listen to his “can do” & “must do” arguments for a fairer world, especially in times like these )  first raised the question, “is health a human right or citizen’s right?” We know the answer to that one. He then shared the historical perspective of the rights of (some) citizens, rights of humans as citizens of some states, and the rights of humans by being “part of the human species”.  He also posited that the world might now require a form of ‘world health insurance’ to realize the right of health. Often it is said that first a World War III (we hope not!!) will be needed before we can get to these global solidarity schemes, but Gorik wasn’t that pessimistic. As for the (few) cynics in the room, even they thought we’re on track for the (US) reasons you know.

Eduardo Banzon from the ADB highlighted the example of the European economic integration and European health insurance card, and asked, “Is economic integration of countries a “must do first” before global UHC? The European participants in the room all gently nodded but instantly also thought that ‘economic unions don’t have eternal life either’, reflecting on the euro predicament in recent years.   He further reflected on the portability of social security benefits including health insurance through the multilateral agreements. Barbara McPake from the Nossal Institute shared her perspective of supply-side harmonization to meet demands of mobile populations and suggested balancing insurance-based resource flows with direct funding for disadvantaged parts of the system.

Carlos van der Laat from the IOM reflected on the policy responses to migrant health issues, and shared IOM’s success stories in monitoring migrant health, establishment of partnerships and networks, policy and legal frameworks, and IOM’s interventions for making health systems ‘migrant-sensitive’. Juan Carlos (from University of Utah, not the former king of Spain) shared his reflections on insurance portability in Latin America and the Caribbean within the context of free trade of services, and elaborated on the unilateral (independent from agreements) definition of beneficiary, local laws forcing migrant workers/investors to choose insurance schemes, and agreements to provide services to poor populations from other countries.

I highlighted the need to collate evidence on the political, economic, and health benefits of UHC beyond borders. Bringing in the perspective of patients, I stressed the need to enhance patients’ knowledge of their entitlements and building their trust in the new health system. Felipe Sere – an Emerging Voice from Uruguay asked, “if the health should be delivered as a product or a right?” Commenting on the ways of engaging with private sector, he inquired “should health insurance be run on the same principles as of car insurance?” Which made us wonder, as he was clearly on to something, why he refrained from comparing health insurance with the Samsung Galaxy Note 7 insurance J!  Soonman Kawan from the ADB summarized the session by asking if the term “beyond borders” only means beyond geographical boundaries or in the true sense, if it also encompasses different population groups with varying citizenships within countries.

To conclude, this session brought an interesting discussion on the extension of global health values of equity, social inclusion and justice, beyond borders. The key message to emerge was, is there a way that the global health community – within the current economic and political trends – can collectively engage in making health a human right and not a citizen’s right?

Declaration of conflict of interest: we have no competing interests