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April 2010, Volume 60, Issue 4


Choked Pipes — Reforming Pakistan’s Mixed Health System

Sania Nishtar  ( Heartfile, 1 Park Road, Chak Shahzad, Islamabad )

I am grateful to JPMA for offering me this opportunity to present a snapshot overview of my book, Choked Pipes: Reforming Pakistan\'s Mixed Health System.1 The book is framed on the central theme of health systems reform, with Pakistan\'s mixed health system as the peg, and with a reform agenda specific to the country. Beyond this however, the book aims to achieve many other objectives, with analytical relevance to broader systems of governance within Pakistan as well as health systems in other developing countries.
Implicit in the analogy with a \'choked pipe\' is a reflection of the magnitude of the problem. Pakistan\'s health system is beyond quick fixes and is in need for deep rooted reform - but so are other social sector systems and many state processes within the country. Much of the discussion in the book is around the salience and nature of these systemic challenges and the means of their mitigation.
Drawing on insights from a review of Pakistan health system the conclusions presented underscore the need for reform in key areas relevant to governance at the broader state level as being critical to the success of reform within the health system.
The analysis demonstrates the linkages of broader measures within the space of the country\'s macro economy - debt limitation, fiscal responsibility, revenue mobilization - systemic interventions in the labor market and reform related to public finance management and civil service structures, with health systems reform. The discussion also dwells on the questions of judicialization of health rights, overall transparency promoting measures, and effective systems of local governance and their relevance in relation to health systems strengthening.
Within the sphere of the health sector, a set of policy, legislative and institutional measures have been outlined and a roadmap for reform has been articulated, which can be implemented in a phased manner. In doing so, there has been an emphasis on making pluralism in service delivery work for equity and quality, capitalizing the strength within public-private engagement and reforming Pakistan\'s extensive public sector service delivery institutional arrangements through regulatory interventions. A range of measures have been set forth to broaden the base of public means of financing for health, drawing on the comparative advantages of a range of stakeholders. The reform agenda acknowledges the institutional implications of systemic restructuring of financing and service delivery arrangements and therefore recommends changes at several regulatory, normative and oversight levels within state agencies with regard to health governance.
The publication has also attempted to acknowledge the impediments to implementing the reform agenda articulated therein by emphasizing that the multidimensional nature of reform proposed in the book necessitates "political will, perseverance, consistency of policy direction over time, and the resolve and capacity to cascade multidimensional changes in a sequenced manner as tangible action into policies, laws, and institutional arrangements". The imperatives to overcome these systemic constraints stem from a two fold realization. One, the need to improve returns on spending in the health sector, in view of Pakistan\'s prevailing macroeconomic downturn, by seeking to address constraints imposed by poorly functioning public systems; and two, the overwhelming need to build country capacity to deliver welfare in the wake of Pakistan\'s current geopolitical challenges.
There are indications that the book will have broader international appeal, beyond its relevance to the health sector in Pakistan. At the book\'s pre-launch preview in Havana last November, the Nigerian Minister of Health Adenike Grange referred to the description of health systems issues in Pakistan as mirroring problems endemic to Nigeria and since the book\'s coming into the public domain, I have heard many others familiar with developing country health systems\' issues make similar comments. I am humbled to learn that the publication will have relevance for other low resource settings; in a sense this is a validation of a theory I had attempted to present in describing the Mixed Health Systems Syndrome earlier this year.2
The book\'s international relevance appears all the more plausible due to the combination of a number of contemporary factors - resource constraints in the aftermath of the global financial crisis, concomitant calls to scale up funding in that milieu and hence the need to optimize resources, and most importantly the beginnings of a shift in global health from diseases towards systems as a result of recognition of the limitations of disease-specific approach to meet holistic objectives in the health sector.
Within the context of all these domestic and international considerations, the ultimate success of the publication will depend on how successful it has been to catalyze change with regard to its proposed agenda for reform in mixed health systems. Only time has the answer to that question.


1.Nishtar S. Choked Pipes: Reforming Pakistan\'s Mixed Health System. Karachi: Oxford University Press; 2010.
2.Nishtar S. Mixed Health Systems Syndrome. Bull World Health Organ 2010; 88: 74-75.

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