Structural adjustment in health in Pakistan: defining the questions

Adnan A Hyder

Bloomberg School of Public Health, Johns Hopkins University, 615 North Wolfe Street, Suite E-8132, Baltimore, MD 21205, USA. E-mail: ahyder{at}jhsph.edu

Sir—It was delightful to read the paper on structural adjustment in the health sector in Pakistan by Bhutta in your August 2001 issue.1 The paper provides an insightful review of the impact of structural adjustment programmes (SAP) led by international organizations in one of the poor developing countries of South Asia. However, the paper did not cover a number of issues which are critical to understanding the process of structural adjustment implementation and monitoring its impact, especially in Pakistan.

The paper states that ‘there is little inherently wrong in the principles that underlie SAP ...’ and a little later comments that, ‘thus several prerequisites ... do not exist’.1 First, the notion that the principles of SAP are perfect is highly debatable if it assumes an equitable world—a completely unrealistic assumption. Moreover, it is the implementation of a programme which proves (or not) the impact on health and equity, and as this case study from Pakistan (like others) demonstrates the SAP programme did not have the intended impact. Second, the fact that prerequisites are defined which are non-existent is very queer; SAP is an operational approach and must be based on real life and tangible assumptions—again reflecting a conceptual fault in SAP for improving health in developing countries.

The paper does not raise concerns on the requirement to match programmes, especially SAP, with the needs of the country. The burden of disease in Pakistan presents the challenges of unresolved communicable and child health conditions, as well as an increasing burden of non-communicable diseases and injuries.2,3 In addition, there are the challenges of decision making, system efficiency and governance within the health sector. Did the SAP in Pakistan address these concerns in a realistic and concerted manner? Who designed it and what were the interests of the health sector of Pakistan in implementing SAP? It is obvious that in the absence of such a process of national interest, the outcome of a programme may not serve health or equity issues within the country.

The paper posits the ‘direct’ attribution of anecdotal reports of suicides in the country to ‘unemployment and financial difficulties’.1 Although plausible, it is a difficult claim to make on the basis of no evidence; moreover the attribution of this increase to socioeconomic consequences with such certainty is dangerous. In fact a multi-country analysis has shown that decreasing economic circumstances are associated with an increase in homicide rates and a decrease in suicide rates.4 There is a need to study the anecdotal reports of increased suicide rates to assess if they represent greater diagnosis or a real increase; define the descriptive epidemiology of such cases; and perform more analysis to see what may be the potential risk and causative factors. In the absence of intentional and unintentional injury information from Pakistan, explicit attributions such as this must be avoided.5

In describing the impact of SAP on the common people, the paper comments that although there is an ‘elaborate social action programme’ to provide basic amenities and social services to the people of Pakistan, it is ‘dysfunctional and inefficient’.1 There are no references for this statement and no evidence is presented to prove this assumption. Again, this must be interpreted with care as such statements provide judgment against large programmes without demonstrating rigor. Data must be presented to certify such claims.

The paper is a first review of the impact of SAP in Pakistan and raises important concerns about what should be done in the immediate future in Pakistan including:

This paper provides a very useful review of the health (and social) impact of SAP in Pakistan, and raises additional questions. It is time to carry this analysis forward into the empirical realm and strategically use it for national dialogue with donor agencies.

References

1 Bhutta Z. Structural adjustment and the impact on health and Society: a perspective from Pakistan. Int J Epidemiol 2001;30:712–16.[Free Full Text]

2 Hyder AA, Morrow RH. Applying burden of disease methods in developing countries: case study from Pakistan. Am J Public Health 2000;90:1235–40.[Abstract/Free Full Text]

3 Pakistan Medical Research Council. Health Profile of the People of Pakistan: The National Health Survey of Pakistan 1990–94. Islamabad: Government of Pakistan, 1997.

4 Buvinic M, Morrison AR. Living in a more violent world. Foreign Policy, Spring 2000;118:58–72.

5 Ghaffar A, Hyder AA, Shaikh I, Mastoor M. Injuries in Pakistan: directions for future health policy. Health Pol Plann 1999;14:11–17.[CrossRef][ISI]


 

Author's response

Zulfiqar Ahmed Bhutta

I would like to thank Dr Hyder for his valuable comments and critique on the recent review of the impact of structural adjustment programmes (SAP) in Pakistan.1 The review of the impact of SAP was not just on health, but also included wider societal issues such as education, poverty and social milieu, a point that Hyder may have missed in looking for empirical data. While a fair amount of objective quantitative information on health and nutrition related outcomes from serial representative surveys was included, we agree with the continued need to critically evaluate the impact of structural adjustments and macroeconomic policies on health and society in developing countries. This was the underlying theme of my submission and I think that Dr Hyder's comments are also supportive of this.

Firstly, to the fundamental issue of whether SAP are flawed. There is no incongruity in the paragraph from which Dr Hyder cites rather selectively and the statements should be read in logical sequence to be meaningful. I stand by the opening remarks that the fundamental principles underlying SAP are sound, namely to bring about fiscal responsibility and prevent profligate spending and borrowing by governments, frequently beyond their means. This issue is common to both external economic assistance and SAP, which are frequently intertwined.2 Pakistan and Argentina are cases in point where despite large inflows of external aid, rampant corruption, fiscal mismanagement and irresponsible borrowing have left both countries teetering at the brink of economic disaster and default. I would also submit that such economic belt-tightening under SAP is entirely possible in circumstances where financial discipline and democracy are coupled with respect for equity and human rights. There are indeed a few relatively recent examples where it has been possible to bail out countries from precarious economic circumstances through disciplined SAP such as those implemented in South Korea, Malaysia and Mexico. The premise that all developing countries are generically incapable of meeting these conditions is therefore incorrect. On the other hand, it is also true that the international financial agencies and lending institutions, though happy to lend, have little stomach to oversee or ensure equitable distribution of their largesse and development of social safety nets.3 If the latter issue could be addressed, structural adjustments could indeed prove beneficial to economic stability and development. Pakistan is again a case in point where although structural adjustments may have kept an otherwise doomed economy afloat, successive governments have had little stomach to reduce non-development expenditure, or address massive pilferage and waste of resources set aside for health, education and social development.

I also disagree with the implication that the IMF and World Bank should directly assume full responsibility for matching country specific resource allocations with health and social needs. These are primarily responsibilities of the national health and health research systems and require national policies that match resources to needs.4 There is little evidence to support the notion that the health system was functioning efficiently or equitably in Pakistan during the period when SAP were not in place and relatively greater resources were available for national health programmes. However, external agencies should take these ground realities into account while overseeing SAP. Where these safety-nets do not exist or are dysfunctional, the requisite safeguards must be built into SAP agreements and their implementation assured through an open transparent process that also includes representatives of the community, such as local governments.

In response to the comment that the recent trend of increased rates of suicides in Pakistan may be anecdotal or related to ‘unintentional injuries’, I can only paraphrase Donald Rumsfeld, that the ‘absence of evidence does not constitute evidence of absence!’ Dr Hyder is well aware of the absence of a systematic process of monitoring epidemiological time trends for health and social problems in Pakistan, lesser still for suicide deaths. However, the recent increase in reported and documented adult suicides in Pakistan is well documented, has been a subject of considerable attention5,6 and merited substantive comment in the most recent assessment of the impact of poverty in Pakistan.7 The temporal relationship of increased rates of reported suicides in urban Karachi with rising rates of unemployment and poverty is compelling and not mere conjecture. Several groups, including ours, are in the process of collecting further empirical as well as qualitative data on this relatively recent phenomenon in Pakistan. Another dimension of this problem may well be the emergence of a new category of suicide-homicides, such as suicide bombings by unemployed, disillusioned young societal dropouts, many of whom are attracted to fanatical causes.

Space limitations precluded presenting additional references and data on the social action programme in Pakistan.1 The social action programme of the government of Pakistan has also been the subject of great scrutiny and investigation in recent years. While large amounts of money were allocated to this social safety-net, the social action programme has been plagued with waste, pilferage and inefficiency.8–10 It is therefore extremely important that future economic restructuring be coupled with an efficient and transparent social security system, which may help shield the disenfranchized and impoverished masses from the direct impact of SAP.

Notes

The Husein Lalji Dewraj Professor of Paediatrics, The Aga Khan University, Karachi, Pakistan.

References

1 Bhutta ZA. Structural adjustment and the impact on health and society: a perspective from Pakistan. Int J Epidemiol 2001;30: 712–16.[Free Full Text]

2 The World Bank. Assessing Aid: What Works, What Doesn't and Why.Oxford: Oxford University Press, 1998. [http://www.worldbank.org/research/aid]

3 Abbasi K. The World Bank and world health. Focus on South Asia—II: India and Pakistan. BMJ 1999;318:1132–35.[Free Full Text]

4 Bhutta ZA. Why has so little changed in maternal and child health in South Asia? BMJ 2000;321:809–12.[Free Full Text]

5 Jawaid SA. Alarming increase in suicide rate. In: Conscience Calls, Pakistan Medical Journalists Association, Karachi: 2001, pp.32–35.

6 Mubbashar MH, Saeed K. Suicide: a public health problem. J College of Physicians and Surgeons Pakistan 2000;10:315–16.

7 Suicide as an escape from poverty. In: Social Development in Pakistan: Towards Poverty Reduction. Social Policy and Development Center. Karachi: Oxford University Press, 2000.

8 Pasha AG, McGarry MG, Sayeed AU et al. Review of the Social Action Programme. RR 16.Social Policy and Development Center, Karachi: 1997.

9 Pasha HA, Pasha AG, Ismail ZH et al. Revamping the Social Action Programme. PP 18. Social Policy and Development Center, Karachi: 2000.

10 Klasra R. European Union warns against misuse of Social Action Programme funds. Daily Dawn, 12 March 2001. [http://www/dawn.com/2001/03/12/top6.htm]





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