All posts by Raza Jaffri

Pakistan’s health burden

Economy, Health

By Zubeida Mustafa
Source: Dawn

THE government has ingenious ways of naming evils in our society. A ghost school is termed as a dysfunctional institution. Quacks are called “unlicensed medical practitioners”. The National Assembly was informed by the health minister last Friday that Pakistan has 200,000 — bluntly termed — quacks who are posing a serious threat to people’s life.

This unpleasant fact of our health system has been known generally for long. But what has not been fully known so far is that conventional wisdom regarding the flaws of our health delivery infrastructure needs to be updated.

It is generally believed that quacks flourish because health facilities are not accessible to the common man who is forced to visit the so-called unlicensed medical practitioners when he falls ill. The government is held responsible for this failure since it has not opened enough dispensaries, clinics and hospitals to address the health needs of the ailing population.

The data released by the federal health ministry for 2006-07 is quite dismal. With the ratio of one doctor to population being 1,475 and one health facility catering to the need of 11,413 people, we cannot really expect the scenario to be satisfactory.

Besides, national averages present a distorted picture. For instance, if the health facilities are concentrated in the urban areas when the bulk of the population lives in the countryside, most people would be denied easy access to healthcare. Thus there are only 595 basic health units in Pakistan which is said to have 45,000 villages.

It can be said that people are forced to turn to quacks. And that is why the government does not even bother to crack down on them because it knows that it does not have the capacity to provide the service, howsoever spurious, the quacks are providing — while posing a serious threat to the lives of many people.

However, an uneven picture emerges in the urban scene. Many low-cost primary health facilities catering to the needs of the common man have sprung up in big cities like Karachi and Lahore. parchi

Those set up by the private sector charge a fee, but a nominal one (ranging from Rs30 to Rs100), which people pay willingly if they are assured of good professional care. Besides, some departments of the public-sector hospitals offer excellent services while charging a few rupees — the fee as it is called since Gen Ziaul Haq deemed the people to be undeserving of any free healthcare whatsoever.

In the government hospitals the services offered depend on the head of the department concerned. If he is an honest, compassionate and dedicated medical practitioner with a vision he manages to uplift his department notwithstanding the constraints a public-sector institution faces.

There are quite a few such examples, the Sindh Institute of Urology and Transplantation being a notable one. With an OPD attendance of 700,000 patients per annum, the institute has come a long way from its humble beginnings. It has grown into a leading urology/nephrology centre in Pakistan that does not charge a penny from its patients and has an international standing.

All this is not enough. Many people have remained outside the pale. That has benefited the quacks. Cracking down on the quacks will drive them underground if alternative facilities are not provided. In this situation it is shocking to see how minimal the government’s role has been in the area of preventive medicine. Reducing the incidence of disease would automatically reduce the burden of the health sector. This has always been the Achilles heel of our public health system.

It is well known that sanitation and the supply of potable water would cut down phenomenally diseases, especially diarrhoeal disorders and parasite-borne illnesses. The dissemination of health education can also help people lead healthy lives without visiting hospitals and doctors to obtain treatment.

Why is it not being done? We do not know where the funds for sanitation, the malaria control, AIDS prevention and family planning programmes and immunisation drives go. These efforts do not appear to be paying the expected dividends although none call for great expertise. But they do call for commitment, integrity and dedication that have been eliminated instead of the parasites and viruses that cause disease.

Another neglected area is that of public health education. The electronic media which should have been an excellent instrument for the dissemination of knowledge on health has apparently forgotten its social responsibility and is more concerned about the rat race. If a health message is linked to an ad — as one exhorting children to wash their hands — it will receive much air time because it generates revenues. But not every message has a commercial dimension.

Health professionals should seek to fill this gap by arranging for trained volunteers to talk to people who visit hospitals and clinics. The waiting room of any hospital or private practitioner is jam-packed. Here many patients would benefit from a health talk. This can be done by volunteers who could be briefed about the kind of information they should disseminate.

Given the prevailing state of ignorance on health matters — even the educated are not always well-informed — and the constraints on time that doctors are faced with, it would make a difference if enlightened and educated volunteers talked about health issues as patients await their turn.

This would certainly help to reduce the disease burden in the country and lighten the load on the health sector. It would also improve the quality of life, enhance productivity of the labour force and upgrade the academic performance of students.

A study estimates that childhood and infectious diseases (most of which are preventable) account for 66 per cent of the burden of disease in Pakistan. Chronic diseases and injuries were among the top 10 causes of HeaLY (Healthy Life-Year) loss. With health education, the spread of disease can be minimised.

What the Future Holds for Flood-Affected Pakistanis: Will Zuhra Go to School Again?

Children and Youth, Natural Disasters, Women,

By Zubeida Mustafa
Source: The WIP

Zuhra is four and she has recently learned her Sindhi alphabet – 52 letters in all. She wants the world to know about her achievement. When I met Zuhra at the Indus Resource Centre’s (IRC) tent city for the flood affected in Dadu – a small town in Pakistan’s southern province of Sindh – she tugged at my sleeve and insisted I listen to her recitation.

Data collected from IRC tent cities in Khairpur, Dadu, and Sehwan in Sindh provides an idea of how women fared the ravaging floods in July through September. Of the 8,089 people housed in these camps, 49 percent were females and 47 percent were children, indicating the prevalence of large family sizes and its implications for women.
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Will Zuhra Go To School Again?

Children and Youth, Natural Disasters, Women

The floods of 2010 have been forgotten. Do we remember the plight of those who suffered. This article was written when the displaced people were returning home. They were happy to be going back to their villages. But their feelings were also marked with trepidation What did the future hold for them?

Today we know that the flood victims have been pushed back into their suffering. It is time we remembered the flood victims. The government is so caught up in crises of its own making, that nothing is being done to rehabilitate the victims. This article has been put up here as a reminder that the miseries of the flood victims are not yet over.

Click here to read the full article.

What next for flood victims?

Economy, Natural Disasters

By Zubeida Mustafa
Source: Dawn

THE narratives of Pakistan’s flood experience are drawing to a close. According to the National Disaster Management Authority’s latest data (Oct 30), 1,984 people lost their lives in the deluge that swept across large tracts of the country.

Nearly 1.7 million houses were damaged and 20.1 million people affected. Gradually, the displaced persons are returning to what were once their homes. If the long queues of wretched flood victims sitting by the roadside awaiting relief are gone and TV talk shows have reverted to the stuff that passes for politics in Pakistan, it doesn’t mean that life is back to normal. Some flood victims still remain in tent cities. Their presence is a powerful reminder of the inept ways of a government trying to cut corners.

Those left behind comprise mainly victims whose homes and lands are still flooded, as in Dadu district. A network of roads built thoughtlessly at an elevated level have facilitated communication no doubt but at what cost? They have trapped the water in the plains and now people simply have to wait for the water to evaporate.

Even those who have managed to return do not have much of a future to look forward too — at least right now. A lot of scepticism is being expressed. In a natural calamity the immediate need is to organise rescue operations and provide relief to the victims to ensure their survival. That phase has passed. What next?

The NGOs and community-based organisations that did a lot in the first phase do not have the financial resources and manpower for the rehabilitation stage. There is also the trust deficit vis-à-vis the government that marks the public’s perception of how the emergency was managed. Thus the truth may never be known about the breaches that were made in the embankments of rivers ostensibly to save the barrages. Besides, there is a widespread impression that the government is not performing.

Isn’t it time for the government to draw up reconstruction plans and start putting its act together? It is important that transparency is observed at every step. Every government department now has its website. A ‘flood rehabilitation’ section must be created where the goals and timeframe for rehabilitation activities are posted. Information about the implementation of the plan should be given on a daily basis so that interested parties can monitor the official performance. The need is to make the government accountable to the public.

This approach may cause less discord and it would certainly reduce the blame game in the provinces if Islamabad distributes the resources for flood rehabilitation among them, allowing them the autonomy of decision-making on issues of local concern. The criteria to determine each province’s share of flood relief funds should be the extent of damage caused and the number of people affected.

In other words this means that the precise extent of the damage should be posted on the website even before aid disbursement begins. What form should this take? The idea of doling out money is simply repugnant. It is not good for the self-esteem of people to make beggars out of them. The complaints against the Watan cards demonstrate that a strategy of distributing funds for reconstruction is inherently flawed in a country where corruption is rife.

As an emergency response it is understandable to initially help people by providing them cash. But thereafter it is important to provide them the means to help themselves. From Nadra’s account it seems a million cards will be processed. Even if we assume that they will go to deserving cases it works out to one card for 20 people — will Rs1,000 per head suffice?

If we do not want starvation to be the next crisis it is time the government thought about the food shortage that is inevitable. The tillers of land should be encouraged to grow vegetables on small plots. Some have received seeds from NGOs. Others should also be provided seeds.

Since most small farmers do not own the land they cultivate, it is important that they be allowed to grow their food on the fringes of the land where the cultivation of wheat, sugarcane, rice or other cash crops takes place.

It is time the big landowners allow this facility to their haris — it is their moral duty to do so. No landowner is known to have assumed total responsibility for the relief and rehabilitation of his farmers. It is time the landlords were asked to do so.

Most important of all, the reconstruction of the infrastructure that is undertaken should be guided by some basic principles. First, no contractor should be hired. Second, all labour should be indigenous. Third, jobs should be created and the flood-affected people hired on a cash-for-work basis.

The floods have opened a window of opportunity for change. The tent cities set up by well-established organisations that collected data have come out with some horrifying information. Literacy rates and school enrollment ratios are much lower than what the government claims. The fertility rate in these areas is very high. The status of women is shockingly dismal.

Anecdotal evidence suggests that accessibility to schools and health facilities is virtually non-existent in many areas. Either these institutions are non-existent or if they do exist they are dysfunctional for various reasons.

A number of flood-affected children have tasted the joys of schooling and adults have experienced the comforts of healthcare in the tent cities where they were housed. It will not be easy to push them back into the Stone Ages and expect them to submit to the indignities of a subhuman existence again. Discontent will rise and its target will be the oppressors of the suffering haris.

If good sense prevails, it is time the cataclysmic flood prompted our rulers to do some long-term thinking on the unfair tenancy laws, the inequitable land ownership pattern and the unequal taxation principles that hurt the poor and benefit the rich. Will those who have suffered put up with this injustice indefinitely?

On the point of change?

Natural Disasters, Social Issues

By Zubeida Mustafa
Source: Dawn

THE tent cities for the flood-affected in Khairpur are now being dismantled. According to the EDO of the district only five remained last Friday.

As I watched the occupants of the Indus Resource Centre’s (IRC) camp prepare for their return journey, I wondered if this watershed event in their lives would also prove to be the turning point. For two months the trauma of the flood’s ravages became a distant nightmare as they lived in a new caring environment they had never known before.

The question is whether this experience will move them to change their lives radically. The two tent cities organised by the NGO in Dadu and Khairpur, where I spent several hours with the flood victims, provide a textbook example of what development is all about.

Sadiqa Salahuddin, the executive director of IRC, who is far from being a desk-bound activist, summed up the choices before the displaced people in her farewell speech. “Your children [there were 685 among the 1,221 victims] were so happy here and we hope you will also keep them happy. Be gentle with them as well as with their mothers. You were also happy here. Take back these memories to give a new direction to your lives,” she exhorted them.

From August to October, it was not just their basic necessities — mainly food, water, shelter and healthcare — that were attended to; their children received schooling, their women got guidance in handicraft and lessons in reproductive healthcare and the men learnt the virtues of living in harmony.

This was done by setting up schools in the two camps I visited, organising health and sanitation education classes, workshops for handicrafts and setting up a conciliation council comprising leaders of different clans to take collective decisions and resolve disputes.

Here was participatory governance at its best. Some teachers and camp managers had to be hired from outside (but from the local population) as expertise was not available among the affected. But assistants — teachers and managers — and manual labour for any project undertaken came from the inmates of the tent cities who received due emoluments in cash.

According to the executive director, it was a record of sorts that no violence occurred in the camps, notwithstanding the diverse backgrounds of the people thrown together by the doings of nature. It was amusing to see a police guard deployed per routine trying to make his presence felt by unnecessarily throwing his weight around.

This participatory form of governance must continue if lives have to change. Sadiqa Salahuddin’s advice to flood survivors carried weight. They could empower themselves if they lived peacefully and did not allow their enemies to hurt them by dividing their communities. haris

Of course it will be a challenge for the flood victims to replicate their camp life in their impoverished home environment. Lacking political empowerment they have to struggle against socio-economic odds that are daunting. Land owners can be tyrannical when it comes to exploiting their to extract undue privileges for themselves. Denied the benefits of good education and the basic facilities of healthcare, family planning, sanitation and nutrition, the farm workers are unaware of the rights they are entitled to.

Nevertheless, the parting message was, ‘Help yourself and we will help you’. The emphasis was on self-reliance and dignity. To show the way, gifts were handed out — tools (shovels, spades, saws, etc for the men), kitchen utensils for women and schoolbags for children (courtesy Unicef). Families were given dry rations for a fortnight and seeds to grow vegetables. Earlier they had received beddings and were allowed to take their tents with them.

Most of them live on land that they have no title to. They were leaving with mixed feelings. They were satisfied and grateful but also pensive. The good times were drawing to a close (evenings had been occasions for folk music and women had been spared the violence that was their fate earlier on). Above all, they were stepping into an uncertain future.

But at least, the first stirrings had been created in a people who had previously shown little interest in sending their children to school. The young ones had became absorbed in their lessons — there were three- and four-year-olds who tugged at my sleeve demanding that I listen to them recite rhymes and alphabets. Will this interest blossom into something more? wadera bara

Many villages have no schools. There are others where the uses the school building as a for his cattle. Others have schools but no schooling. The people lack the means and organisation to pressure the government to safeguard their rights. Two months were not enough for them, the weaker party, to acquire the skills to neutralise the levers that are traditionally used against them.

But there is hope. Seeds of awareness have been sown, new relationships forged and new friendships struck. Ingenious uses of the ubiquitous mobile phone are being discovered. Above all, they have been promised continued support to keep alight the flame that has been lighted. wai

Ali Madad, an IRC project officer who helped with the Khairpur camp, captured the message poignantly when he recited Shaikh Ayaz in -style: When the red roses burst into bloom/We will meet again.

Much now depends on the government. Last week it appeared to be nudging the NGOs out of this space some of them have created for themselves in the life of flood-affected communities. It declared that henceforth the government will manage the $3bn additional aid it was seeking.

Will it be used to dole out meagre charity to individuals to hurt their dignity? Or will this aid be used to stimulate economic activity in the flood-ravaged regions to rebuild the infrastructure on a cash-for-work basis — albeit keeping contractors out and employing only indigenous people?