Political will or ill-will: The case for “Population” in Pakistan

The rapidly growing population in Pakistan, and its horrible consequences have been known & articulated by all the stakeholders including especially the Government and donors, besides the civil society.  A quick look at historical evolution to address this issue reveals that at the end of the day, it’s the political will or otherwise which makes a difference.

Modest but impressive beginning

In ’60s, FP (Family Planning was initiated by an NGO, which made a big difference to capture the attention of Government and later within some decades we had a formal Ministry of Population Welfare and a famous program of Village Based FP Workers along with mobile clinics etc.  Interestingly this was even before the existing Lady Health Worker Program

Good intentions but bad consequences

The Government appeared to have good intentions in having two ministries i.e. The Ministries of Health,  and Population Welfare at Federal level and similarly at the Provincial level.  Perhaps the rationale may be to have focus and desired emphasis on population issues.  However, this artificial divide resulted in compartmentalized approach by putting all the health related issues to Ministry of Health, except for FP; though some lip-service was still maintained.  This issue has further worsened by the devolution in Pakistan and each province is addressing this issue separately; some not paying attention because ‘their’ population is already very low and thus federal distribution of money is also less!!

Playing with Population data

The population have been produced but there had always been issues related to projections and of course fudging of the data at health services delivery levels because of stringent requirements and consequent punitive punishments.  Thus, usually, with few exceptions, the news was that all is well and we are slowly progressing in increasing our contraceptive use rates and the consequent indicators. It was untill when PDHS 2007 and later on 2012 revealed that all is not well.  I remember that the Ministry of Population Welfare held back the results for more than 6 months.  In the meantime several surveys and consultancies (Technical Assistance) work had been conducted to identify the reasons and suggest the solutions. Of course each time we came up with the ‘old wine in a new bottle’.

FP agenda further widened & its consequences

The ICPD agenda and further declarations coined the word for ‘Reproductive Health’ (RH) and then even Sexual and Reproductive Health and we joined the bandwagon as part of political will and international signatory.  I have all the fears that it further diluted the FP focus but opened up the doors for new interventions. This followed the advocacy for Adolescent Health, Abortion Rights, Women sexual and Reproductive Health and lot of talks on population bulge, the demographic dividends etc etc.

Failed efforts for integrating Health & Population

There had always been growing realization that population is part of health and why not the two Ministries be at Federal (before devolution) and Provincial levels be merged. There have been lot of efforts by the UN agencies to make it a reality and I know that even there was all the willingness to do it by the head of state, but just because of one of minister it was postponed and in a way cancelled.  There are some services provided by both the Departments’ outlets and outreach workers but still each one respectively reports to their parent department.  In addition, though some efforts had been made by the other sectors such as education, it has not made a big difference.

Should we keep on using the old wine in a new glass? The way forward

“We cannot solve our problems with the same thinking we used when we created them”, Albert Einstein.

One might be shocked when you start calculating the amount of money put by the Government as well donor agencies and international NGOs to address the issue of FP. Interestingly, most of the NGOs and implementing partners have always showed that they have made a difference in their 1-5 years project. Unfortunately, when money and inputs finishes, all goes to ground zero and no replication, what to talk about scaling up.  Perhaps, all the stakeholders and champions have to make some ‘hard’ and ‘bad’ decisions. It appears the existing government and may be the coming government will not have FP in their political agenda, as they have so many other ‘pressing issues’ to tackle.  But, the question is, has any bilateral, multilateral and Bank has to courage to make these steps; or should we leave it to civil society or at the last to people themselves.  Maybe, let us leave it to Allah, as now we have major populist Islamic dominance who are also not in favour of addressing FP issues.

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Educational & Intellectual corruption: The case for Medical & Public Health fields

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What is it ? 

Corruption is the abuse of entrusted power for private gain. It can be classified as grand, petty and political, depending on the amounts of  lost and the sector where it occurs. We in Pakistan, have been discussing, especially in cable networks & social media about the “corruption” in context of money, especially after PANAMA leaks and very recently the Paradise leaks. However, another big evil in our society has been the “educational corruption”; it usually follows or sometime exclusively exhibits as “intellectual corruption”. I was surprised to see by searching in Google, About 7,960,000 results (0.51 seconds).  Like other fields, corruptions in medical and Public Health is not an exception.

Story of Medical education & practise

The story begins with admission in a “private” medical college, where special seats, foreigner seats or donation-based admissions are highly promoted. I am witness to a parent (landlord) who wished to get her daughter admitted and I suggested him to actually use the money (quite a lot at that time) to give it to her as a dowry. He in fact said that she is becoming a doctor to get some good name and a proposal matching to their standards.  This follows by the “tuition” system, whereby there is a longer & shorter duration contract along with the guarantee to pass the student; of course all manged by the respective faculty member.  Well, leaking paper is of course no exception and even ignoring cheating being widely practised. More interesting is the fact that when an “honest” teacher (usually a Head of Department) sends the results without maneuvering, the respective University staff sends it back mentioning that there is something wrong as 10-15 students have failed in that subject.  Thus, the Principal calls him and argues by mentioning that since the parents are paying handsome money, they expect their children to pass each year.  The story keeps on for internship whereby cronys are entertained and even the post-graduate exams. in which there are some ‘favourite’ candidates.

The Public Health saga

The Public Health education is even much worse than medical education.  Here there is a bigger motive and incentive for owners/managers of the institution to earn money at any cost.  This would mean admission criteria will be wavered off, entry exam will be easy, and any candidate having completed 14-16 years of education will be legible to admission. Then, there will be half-a-day, evening , weekend and even no classes and of course exams and results may also be manipulated. The external examiners for thesis will be the ones who are ‘well-wishers’ of that institution.  Above all the faculty is told that as long you are able to get the admission of X number of candidates, your job will continue.  So the poor faculty, has to do their best to get enough students and have a “good” reputation, so that the cycle keeps repeating.

All the above results, inevitably, into the products who are out there in various institutions and hospitals and serving people and various other stakeholders. There is another dimension to intellectual corruption which is observed in health related institutions, whereby the employees (of any level tend to keep on neglecting the truth & denying the facts, just because that’s not their organization’s ‘punchline’ or more so because they don’t want to get labelled as ‘bad’ guy at the cost of losing their jobs.

The consultancy gimmick

The other intellectual corruption, is practised in awards of contracts, whereby networking, under-table deals or already decided party is unduly favoured. The reports prepared are ‘modified’ to suit all the audiences and only those points are highlighted in big ‘dissemination’ seminars which suits to bot donors and the ones who gets the money; sometimes even for the government department. Highly talented experts sitting in government institutions either keep quite to promote/advocate what the big ‘bosses’ wish to project; they even don’t argue in those high level meetings.

Is this reflecting our society??

Well, one can say that is an echo of a frustrated person, however I can bet that most of us may have encountered, observed or heard stories shared above.  How long can we keep on acting like a hypocrite in spite of the fact the truth is something else.  We are not only producing but also setting the role models as to who can be successful in the medical and public health career.  Can some of us, stand up and play the role of  “whistle-blower” and point out the evil-doers. Perhaps we, including myself are afraid to do this.  However, I fear that I will, like others may be made accountable for not doing anything against this “zulm”. MY only satisfaction could be that I am trying to show just the tip of iceberg and really fear of the consequences.  May be its the reflection of our society which has deteriorated to that extent.

TAKE OUT “GUNJAISH” گنجائش نکالیں

In Urdu, like for any other language there are so many unique words which may not have the exact translation or meaning as it may have otherwise. In addition, some words (just as Arabic), in Urdu have so many meanings and could be attributed to a particular situation.

So what would be probable meaning of Gunjaish?? Let me try some of them:

  1. If you are shopping and trying to bargain then you can use it for suggesting discount !!
  2. To be considerate or accommodative
  3. To forgo and forget
  4. Let it go

So how all this started; this can be a usual situation; you are supposed to be in a meeting or attending a workshop or attending any party at a described time and place. You out of good etiquette reach on time (may be with many others) and the ‘Facilitator’ of meeting or workshop is also there but there are few (or even half of them) who have not turned up.  Everyone is waiting and/or started looking at their mobile and started surfing around or busy with FB.  Someone like me is anxious to get that meeting done and sort of requests the facilitator to commence it.  And, you get an interesting answer “Dr. Sahib Zara Gunjaish Nikaley”.  And then the debate starts.

We as human beings have not only lost patience but also have forgotten that our behavior are not only reflections of the situation but how we respond, react and attribute to a situation. In that context, we many of the times fall into “stereotyping” and respond, “why should the early birds or those on time suffer for those who are late, may be because they are used to it; or its their habit or do not bother about others. However, there may be some alternate issues which would have delayed the presence in meeting, such as emergency at home; missing the alarm; traffic jams due to VIP moments etc. Thus, then the Gunjaish can have even a wider meaning of “let it go” or be empathic to others. Perhaps, we in this materialistic world have become more of self-centered and wish to see the whole world in our own way.

So giving “gunjaish” is one sided or two-sided.  If the act of delayed reaching at a meeting is deliberate or due to negligence or ill-planning, then why can’t we be more considerate so that others are also do not suffer.  Nevertheless, understanding and practicing of “Gunjaish” has made a big difference to me… so do you?

Higher education programmes: Planning, Challenges and outcome

Pakistan is faced with major task of increasing its basic primary as well higher education; leave alone how and in what fields the products will be utilized.  Today, I will be focusing on higher level education illustrating a comparison between two programmes; one is BSc and other is MSc.

Last days as part of my consultancy work I have been working on evaluating the BSC-Midwifery programme.  This is is one of the pioneer initiative supported by a UN agency and being implemented by School of Nursing and Midwife of a prestigious university. I was surprised and rather embarrassed by the fact that it has been scientifically and strategically designed alongwith international and national consultations and with full support of Pakistan Nursing Council (PNC) and Midwifery Association of Pakistan (MAP). In addition to that there are other groups who are either running the similar programme or in fact have also developed a draft “Midwifery vision 2025”.

so what was embarrassing to me??  Well after spending almost three, decades wherein a bunch of seven “preceptors” working in Community Health Sciences Department ( from 1985) who had then be practicing as well advocating for the role models, and later on joined by so many Public Health experts including the PhDs, we have not been able to achieve the following:

a) A strategic planning for the syllabus and curriculum;

b) no functional and active association (have been having off & on) and

c) no regulatory authority to ensure quality of products (PMDC has its own challenges and rules of business).

I can even add, in this list a dedicated and highly esteemed “Journal focusing on Public Health” issues; we have produced many papers, mainly to beef up our CV.

So where the things have gone wrong.  One can come up with lot of semantics and rhetoric, but as a ‘hopeful pessimist’ I feel that our (Public Health graduates) education/training, job opportunities and the contribution which should have been made to address health challenges –all are showing a downward trend. I am proposing that the academia, teaching institutions as well the young graduates should have to address these issues. My long time observation is that we are not ready and even willing to challenge the status quo, simply because we wish to save our job, consultancy opportunities or just least bothered. We attend big workshops and conferences with luxurious lunches, talk all the good things which everyone wishes to hear, make resolutions and then forget all.  How many of us, including myself is wiling to challenge that building more hospitals are not the solution, that supplying ready to use foods can be replaced by simple home made techniques, and that institutions are not putting lot of efforts to produce high quality graduates.

All is not well !!

RANDOM THOUGHTS: questioning the solutions

It indeed had been quite a long time that I have not been writing a blog; perhaps my un-wanted engagements or to be more precise distractions to the social media especially FB, which I definitely find more enjoying but time-consuming. Nevertheless though I will sharing my “Journey from Thar to Islamabad” which indeed is very near to my heart but may pushing myself to write the third Episode of that journey had deterred me to share some of my random thoughts.

I am not sure how many of you know about David Werner, but he has been well known working with Hesperian Foundation.  And some of my colleagues and friends would bear me out, I had the opportunity to work with him when he visited the Aga Khan University back in 90s.  To cut short, he is the author of “Where there is no doctor“, one of the few famous books translated in many languages and a good resource for grass root level workers.  Among other works, he has challenged the status qua by ‘questioning the solution’.  Its high time that we in Pakistan also start “questioning the solutions”.

The Public Health practices and its focus on improving the health of the people has undergone so many changes/improvements and of course improvement in health status in Pakistan.  However, we have also come up as well as recommended a number of solutions which though apparently seem to be working but we are not raising the questions whether its the right solution or not?? Back in 80s David had challenged  about the role of village health workers which in our new terminology can be equated with more or less similar workers; to a name a few, are the CHWs and CMWs. When both of these programmes were launched the idea should have been to help the community for ensuring access to basic health services and and in that process make the community/beneficiary to take care of their health by themselves.  However, with the recent move for getting more political gains, the services of CHWs have been regularized or recognized by government with some salary.  Similarly, the CMWs against what it stands for i.e. the community based and patient-centered care is incentivized for establishing some static facility and push the community for having that care as opposed to old age home deliveries.  I am, by no means, asking the planners to move towards deliveries without basic skilled birth attendance, but to just not ask the community to change their whole old-age behavior (see my earlier blog on how my brothers were born) of having their births at home.. by CMWs. Similarly now we are hearing about the so called readily prepared high caloric food being promoted by bilaterals and government (at provincial levels) are ordering it from international markets at a reasonably high cost.  Though fact of the matter is that an indigenously prepared high density diet has already been prepared and successfully test by one of my teachers, Dr. DS Akram. Why this diet has been taken by our worthy planners is another long story.

Questioning the solutions has always been fraught with oppositions and repercussions as you are challenging the status qua. Perhaps we all the Public Health Practitioners would have to at least generate the debate on  pros and cons especially the economics of this approach; then and then  we reach to some better solutions. InshAllah I will be putting more thoughts on these issues; I do not have anything to lose and I can not be part of that “zulm” as I may also be questioned about this on the basis of the knowledge and wisdom Allah has given me.

Village life, values, culture and practices- birthing by Dais

FROM THAR TO ISLAMABAD

As a Public Health Practitioner, among many other issues, MMR, IMR and NMR (neonatal mortality rate) are being focused; now with the induction of CMWs, lot of emphasis is being given on institutional based deliveries by giving the targets to be achieved for various health facilities. We are also guilty of prescribing recipes to mothers for breast feeding, giving the right diet, when to and not to get pregnant, where to go for check ups, where to deliver and so on…  The over-riding assumption for us is that since these are really nice “magic bullets” or interventions and since the mothers/women do not know or even care about it, we should tell them. While doing it we use our “medicalized model” and even undermine the common wisdom.

In that wishful thinking, we even wish to change the centuries old practices and experiences, on which the village life has thrived. Before I come to birthing by dais, let me remind the rich culture and values in village life. Well, the media may have played a role in bringing the ‘development’ of villages, but I believe many practices will be more or less same. The village is something like a large family, everyone knows each other and care for whenever it is needed. The respect for elders is equal disregard of social status; the only source of information as to what is happening in various houses, for ladies is the “bishti” the leather-bag water carrier.  If you lost your parrot, it can be easily located; if you are stung by a scorpion, the local moulvi will do the ‘dam’ and you will be alright.  While going to main market you don’t say that you are going to the ‘bazar’ or for that matter a mall, but you say, ” I am going to the city”.  Swimming in river, playing ‘guli-danda, pittoho, Dhoronaro-white river

and visiting railway station of Dhoronaro (my village name) are the common pass-time activities. These are some of the memories of childhood. And talking about health care, you will be given ‘churan’ which works as a laxative so that you get rid of worms, if you are vomiting, then local herb and lemon is the best. Of course, for delivering the babies the “dai’ or my family called it as “maim saheb”

The importance of “maim shaeb” was realized by me, after quite a number of years, when in fact she visited our family residing in Kaharadar, Karachi, to deliver  my youngest brother. She came with a big suit case and we were told that she has brought for us our younger brother (we were already 5 MashAllah); but she will show us later on.  AND, of course we were shown the baby and she stayed with us for at least a month. When I grew a bit older, then I started finding out from my grand-mamma/daadi as to who was delivered where. And she had some interesting revelations for me. The eldest brother (I am the second one!!) was delivered by a private doctor and in a supposedly expensive hospital/maternity home, as the first baby is always a precious one. I, being the 2nd was given relatively lesser attention, so I got delivered in a charitable hospital of our community. But, then rest of all i.e. the 3 next brothers got delivered at home in the village and the youngest in a flat in Karachi.

so what wisdom or barriers were influencing these practices, which in a way were/are norms for a middle class person residing in a village. Going to hospital for maternity care can easily be explained by us, but we fail to understand why my family did what they should not have done, especially for the last delivery. We in fact tend to understand that getting delivered at home environment is much more practical and congenial to an expectant mother, rather than to go to hospitals. In addition, its the trust and confidence in the maim saheb which encourages these decisions.

The community midwife is by far a good idea, but why on earth we are forcing the mothers to come to health facilities to get themselves delivered, until and unless there is a need to do it or it is by option. I am not totally against the skilled birth attendance, but I am not convinced, the way it is being promoted, inspite of the name CMWs–community midwives. It is os interesting that when in many developed countries, mothers are being encouraged to deliver at home, we are pushing it very hard to break the old age milieu and culture if the intended harms/risks are addressed.