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Abstract
Pakistan currently ranks 154 out of 189 countries on the UNDP’s Human Development Index. In this paper, we use a ‘political settlements analysis’ to understand how the distribution of political, economic and social power explains this ranking and the inequity in Pakistan’s health system. We investigate elite power struggles over the last seven decades to explain how ad hoc policy-making, instability, patronage politics and rent-seeking have led to a maldistribution of resources, lack of oversight, and inequitable access and service provision for a burgeoning population. We argue that these factors have had two consequences: the privatisation of health care, and the opening up of a considerable sphere of influence to the donor community to direct state policy. Despite promising ongoing reform efforts, we conclude that Pakistan’s health system will remain hamstrung by the constraints of a political settlement in which elites with short-term horizons bargain for influence rather than developing an inclusive, consensus-based approach to improving governance outcomes for citizens.
Acknowledgements
The authors would like to thank Ayman Moazzam for his able research assistance.
Disclosure statement
No potential conflict of interest was reported by the author(s).
Notes
1. UNDP, ‘The Next Frontier: Human Development and the Anthropocene: Pakistan’, Human Development Report 2020, pp. 1–7 [2–3] [http://hdr.undp.org/sites/all/themes/hdr_theme/country-notes/PAK.pdf, accessed 3 Sept. 2021].
2. Finance Division, Government of Pakistan, Pakistan Economic Survey, 2019–20, pp. 1–516 [216] [http://www.finance.gov.pk/survey/chapter_20/PES_2019_20.pdf, accessed 25 Oct. 2020].
3. Ibid., p. 226.
4. Poliovirus or wild polio virus has three naturally occurring strains, two of which have been eradicated. Type 1 wild polio virus is endemic in Pakistan and Afghanistan: see WHO, ‘Two Out of Three Wild Poliovirus Strains Eradicated’ (24 Oct. 2019) [https://www.who.int/news-room/feature-stories/detail/two-out-of-three-wild-poliovirus-strains-eradicated, accessed 3 Sept. 2021].
5. Mushtaq H. Khan, ‘Anti-Corruption in Bangladesh: A Political Settlements Analysis’, SOAS Anti-Corruption Evidence (ACE) Research Consortium Working Paper 03 (London: SOAS, University of London, 2017), p. 20 [https://ace.soas.ac.uk/working-paper-3/, accessed 20 April 2021]. A political settlements approach has been used to analyse the health sector in a number of developing countries—see, for example, Tim Kelsall, ‘Political Settlements and the Implementation of Maternal Health Policy in the Developing World: A Comparative Case Study of Rwanda, Ghana, Uganda and Bangladesh’, Effective States and Inclusive Development Working Paper 137 (2020) [https://www.effective-states.org/wp-content/uploads/working_papers/final-pdfs/esid_wp_137_kelsall.pdf, accessed 3 Sept. 2021].
6. For more analysis of Pakistan’s elites, see Rosita Armytage, Big Capital in an Unequal World: The Micropolitics of Wealth in Pakistan (Oxford: Berghahn Books, 2020).
7. Procedural democracy, in contrast to substantive democracy, refers to a form of democracy in which democratic procedures, such as elections, are followed but do not produce results that are representative of the people’s will.
8. Kabeer Dawani and Asad Sayeed, ‘Anti-Corruption in Pakistan’s Pharmaceutical Sector: A Political Settlement Analysis’, SOAS Anti-Corruption Evidence (ACE) Working Paper 025 (July 2020) [https://ace.soas.ac.uk/wp-content/uploads/2020/07/ACE-WorkingPaper025-PakistanPharma-200701.pdf, accessed 12 Sept. 2021].
9. S. Akbar Zaidi, ‘The Urban Bias in Health Facilities in Pakistan’, in Social Science and Medicine, Vol. 20, no. 5 (1985), pp. 473–82.
10. S. Akbar Zaidi, The Political Economy of Healthcare in Pakistan (Lahore: Vanguard Books, 1988), p. 3.
11. Rent-seeking describes an ecopolitical process in which wealth is gained without the beneficiary making any contribution to the processes of production that generated that wealth.
12. WHO EMRO, ‘Health System Profile: Pakistan’ (2007), p. 11 [http://digicollection.org/hss/en/m/abstract/Js17305e/, accessed 3 Sept. 2021].
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14. There are 114 medical colleges and universities in Pakistan, the majority privately owned, which produce 15,000 doctors each year: Wajahat Bokhari, ‘Medical Colleges in Pakistan—Too Few or Too Many?’, The Daily Times (21 Sept. 2019) [https://dailytimes.com.pk/469531/medical-colleges-and-doctors-in-pakistan-too-many-or-too-few/, accessed 25 Sept. 2020].
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20. These range from surgical errors when items are left inside the surgical cavity to overprescribing medicines.
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25. Ibid., ‘Statistical Appendices’, pp. 6–7.
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46. Dawani and Sayeed, ‘Anti-Corruption in Pakistan’s Pharmaceutical Sector’, pp. 13–5; and Siddiqa, Military Inc..
47. Dawani and Sayeed, ‘Anti-Corruption in Pakistan’s Pharmaceutical Sector’, pp. 13–5.
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51. Mushtaq H. Khan, ‘Anti-Corruption in Bangladesh’; and Dawani and Sayeed, ‘Anti-Corruption in Pakistan’s Pharmaceutical Sector’, p. 14.
52. Formed in 1996 with the aim of ensuring justice, Pakistan Tehreek-e-Insaf Party remained out of the corridors of power till it embraced individual interest groups prior to the 2018 election and abandoned any commitment to consistent ideological positions: see Tabinda Khan, ‘Pakistan Tehreek-e-Insaf: From a Movement to a Catch-All Party’, in Mariam Mufti et al. (eds), Pakistan’s Political Parties: Surviving between Dictatorship and Democracy (Washington, DC: Georgetown University Press, 2020), pp. 60–75.
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56. Non-party elections, where elections take place amongst individuals without stated party affiliations, have frequently been used in Pakistan as a means of weakening political parties: see Niloufer Siddiqui et al., ‘Introduction: Pakistan’s Political Parties in an Era of Transition’, in Mariam Mufti et al. (eds), Pakistan’s Political Parties: Surviving between Dictatorship and Democracy (Washington, DC: Georgetown University Press, 2020), pp. 1–22.
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83. Ibid., pp. 3–4
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89. These are locally known as biradari or zaat and are dependent on occupational hierarchies and linked to notions of purity.
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107. Federal Bureau of Statistics, Government of Pakistan, ‘National Health Accounts 2015–16’, p. xii. Family employment in the military is not a condition for accessing medical facilities run by the Pakistani armed forces.
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116. Ibid.
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118. Ibid.
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120. Bhutta, ‘Structural Adjustments and Their Impact on Health and Society’; see also Kabeer Dawani and Asad Sayeed, ‘Pakistan’s Pharmaceutical Sector: Issues of Pricing, Procurement and the Quality of Medicines’, Anti-Corruption Evidence (ACE) Research Consortium Working Paper 012 (London: SOAS, University of London, 2019) [http://www.researchcollective.org/Documents/Dawani_and_Sayeed_2019_PakistanPharmaSector-190801.pdf, accessed 26 April 2021].
121. See papers in this collection on the Indian and Bangladeshi pharmaceutical industries.
122. Matt Andrews et al., ‘Looking like a State: The Seduction of Isomorphic Mimicry’, in Building State Capability: Evidence, Analysis, Action (Oxford Scholarship Online, 2017) DOI: 10.1093/acprof:oso/9780198747482.003.0003.
123. Provincial governments transfer funds (as grants-in-aid) and management responsibility to the Rural Support Programme. Since they are partly funded by provincial governments, there was no open competition for these contracts: for more details, see Malik et al., ‘Did Contracting Effect the Use of Primary Health Care Units in Pakistan?’, pp. 1032–41.
124. Nishtar et al., ‘Pakistan’s Health System’, p. 2201.
125. Malik et al., ‘Did Contracting Effect the Use of Primary Health Care Units in Pakistan?’.
126. Ibid. See also Willem A. Odendaal et al., ‘Contracting Out to Improve the Use of Clinical Health Services and Health Outcomes in Low- and Middle-Income Countries’, in Cochrane Database of Systematic Reviews, Vol. 4, no. CD008133 (2018), DOI: 10.1002/14651858.CD008133.pub2.
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