Reviewing Sania Nishtar’s new book entitled ‘Choked Pipes: Reforming Pakistan’s Mixed Health System’ has been an interesting experience for a number of reasons. A glance through the cover gets you biased outright. A Nobel Laureate has termed the book “magisterial” stating that “[it is] intended not for the day but responds to the needs of an era, written not for a single country but relevant for the intractable health problems of the developing world”. Mary Robinson, the former president of Ireland, a past UN Human Rights Commission chair and now the president of the Ethical Globalization Initiative at the Aspen Institute has termed it a “watershed” in developing country health reform with regard to health as a human right. The World Health Organisation says the book is “ushering in a new science of health systems” and the Dean of the Harvard School for Public Health terms it a “brilliant reform agenda”.
With such stellar endorsements one opens the pages with a mindset already leaning towards a conclusion, but with a burning question—does the book really deserve this unprecedented level of praise? A careful review of the book reveals that the praise is indeed well deserved—and so, for a number of reasons. The book is the first review of Pakistan’s health system, and the first consolidated reform agenda ever developed for developing countries with mixed health systems. Sania Nishtar has tried to cover many bases with one publication. On the one hand, the book is relevant to Pakistan’s macro-economically constrained environment as it chalks out a road map for addressing systemic constraints in the healthcare system and hence enhancing efficiencies. On the other hand, the book is also of relevance to other developing countries.
Professor Anne Mills, one of the few respected names in health reform explain the importance of the book in the international sphere of health reform in her commendation “There is urgent need for better knowledge on how to strengthen health systems, and given variation across countries in many critical elements, this knowledge is best built up from detailed analytical country studies. This book represents an important contribution to the global knowledge base on health systems.” Sania alludes to the international dimension in her book in many places, but particularly in the Précis explaining how a reform agenda specific to Pakistan can be of relevance to other developing countries.
The most interesting part of the book is the description of the pattern of collusion described by the author. Sania Nishtar explains how malpractices are pervasive to the health system at different levels—in hospitals, in field delivery of services, in the drugs and pharmaceutical sector. But she doesn’t do it in a mud-slinging mode. On the contrary. It is done so with a remedial tone. The reform section of the book talks about specific safeguards that can be built to address these pervasive problems. What has been interesting is that it is this section of the book where its international resonance is most pronounced. The book had a Pre-launch preview in Havana, Cuba last November, at the World Health Organization’s Annual Global Forum meeting. One of the panelists of the Pre-launch preview, the Nigerian Minister of Health Adenike Grange referred to the description of health systems issues in Pakistan as mirroring problems endemic to Nigeria when she stated “reading the book, I thought I was reading a description of the health system in my own country”. The other panelists at the pre-launch, in particular, the former deputy Foreign Minister of Japan (in Japan global health is in the purview of the foreign minister) who has been very active in the G8 process referred to the book as an invaluable asset for planning within G8 with regard to development assistance for developing countries. It is for these reasons that many experts are of the view that the book’s international appeal and ultimate impact may eventually be more than its utility in the country.
With respect to the book’s contents, an excerpt from Dean Julio Frenk’s Foreword summarizes the salience of the book: “The main virtue of ‘Choked Pipes’ lies in its clear understanding of the boundaries, purposes, and functions of health systems. This provides a coherent framework for discussing the evolution of the Pakistani health system since its inception, its previous reform efforts, and its present configuration, as well as for presenting a comprehensive reform agenda…The publication ends with a brilliant defense of a realistic but ambitious health reform agenda for Pakistan……The circle is brilliantly closed by the many lessons that this publication brings to the shared search for better health systems throughout the world”. I have enclosed a summary of the book with this review to give a snapshot view of what the book is about.
The analogy with a ‘choked pipe’ is a reflection of the magnitude of the problem. Nishtar makes the point again and again about the need to remedy welfare and social sector systems in Pakistan today. She says 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”. The relevance of the reform agenda and the manner in which she envisages using the public and private sectors collaboratively, therefore, extends much beyond the health sector and can be useful in strengthening the state’s capacity to delivery welfare services, as she rightly explains.
The Reform Agenda outlines four areas for reform both within as well as outside of the healthcare system and envisages implementing these changes in a step-wise manner. “Step I focuses on developing a national consensus on the reform agenda and increasing public financing for health. Step II involves bracing the health information system and pulling a thread through existing evidence. Step III has three components—strengthening institutions; honing norms, and mainstreaming technology. Step IV is focused on prototyping alternative service delivery and financing mechanisms whereas Step V is centered on scaling up.” She lays particular emphasis on generating national consensus for reform “Any effort to mainstream health reform must therefore proceed with a multi-stakeholder sign-up to an Agenda for Reform”. In her detailed account of health restructuring in Pakistan, the de-tracking and re-tracking in planning is alluded to in great detail and has been rightly pointed out as one of the key impediments to reform.
The publication is being released this month by the Oxford University Press. With this book, Sania Nishtar has firmly placed the stamp of her incisive analytical ability on health reform. She has not just analyzed Pakistan’s health sector, she has also given a tangible road map for reform. And nor just that, she has also developed a health policy for the country, which appears as an appendix to the book. All this has been done by one individual. When her earlier book on health systems was published in 2006, a World Bank expert commented on the quantum and quality of the work by stating that “it has taken years of work by many consultants and a huge budget in South Africa to produce something comparable; the fact that this was written by one individual in one year and with no budget is astounding and truly unprecedented”. The publication which the expert was referring to was minuscule compared to the depth of information in Choked Pipes. Ariel Pablos-Mendez, the Managing Director of the Rockefeller Foundation was indeed right when he commented “Nishtar demonstrates a commitment to her people and to society which reminds us of a modern Virchow (one of the founding fathers of public health).” This commendation now adorns the book’s back cover to remind us of the magnitude of the contribution made by Sania Nishtar.
‘Choked Pipes’ — a summary
By drawing an analogy to a ‘choked pipe,’ the title of this publication underscores a key point—systems plagued by systemic challenges simply cannot deliver on desired public policy endpoints. Understanding these issues and the means of mitigating them assume importance in Pakistan at a time when the need to deliver welfare has never been more dire in view of the country’s prevailing geopolitical challenges.
‘Choked Pipes’, is the first consolidated review of Pakistan’s health system, which describes a new syndrome—Mixed Health Systems Syndrome—and the challenges in an environment where publicly-funded government health delivery coexists with privately-financed market delivery. The author’s vision for reform draws attention to a number of structural factors, both within and outside of the healthcare system and lays emphasis on reform of governance and social welfare as an important adjunct to reform within the healthcare system.
The reform agenda proposed herein comes at a critical time in the evolution of interest in global health from ‘diseases’ to ‘systems’ and therefore has a bearing on health systems in other developing countries—most of them with mixed health systems—with reference to current efforts aimed at achieving development goals in today’s macroeconomically constrained environment.