CHUP recently published several posts related to public health issues in Pakistan [see Jehan Riar’s contribution piece as well as this news brief] which generated vigorous discussion among readers. As a result, we thought it both important and timely to interview Samia Altaf, a public health physician whose career has focused on the management and coordination of complex health delivery systems for low-income populations. Following a four-year stint with the USAID mission in Islamabad, she was chosen to be the Woodrow Wilson International Center for Scholars‘ 2007-8 Pakistan Scholar. Dr. Altaf is currently finishing her project at the Wilson Center, entitled, Aid Effectiveness: A Case Study of the Health and Population Sectors in Pakistan. She will be speaking on the topic at the Wilson Center tomorrow, July 9, from 4-5 pm [EST]. The event will be held in Washington, D.C. but will be webcast live, [see Asia Program website for more details]. Below is CHUP’s interview with Dr. Altaf:
Q: According to USAID, Pakistan’s health indicators are among the worst in the world. For every 100,000 children born, 35 mothers die; and over 72 infants die for every 1,000 live births. Communicable diseases such as tuberculosis remain a serious concern. What do you think accounts for such statistics?
There has been no investment in providing programs and services that are consistent, adequate and of good quality. That is what I speak about in my book [Improving Aid Effectiveness: A Case Study of the Health and Population Sectors in Pakistan]. There have been efforts – from 1950 to 1999, there’s been $58 billion invested in Pakistan, but this has had very little impact on improving health and other social services.
Q: What do you feel is the most pressing public health concern facing Pakistan?
There is not one single pressing concern – you can’t just take one issue and fix it. Instead, there needs to be a comprehensive public health policy and implementation strategy.
Q: From 2002 through 2006, USAID provided a total of $449 million to address Pakistan’s most pressing needs: education, health economic growth, and good governance in order to promote stability within the country. How can USAID and other aid organizations improve the distribution of these funds? Should more aid be given to these sectors?
It is not an issue of money. It is not about distribution of funds. Clearly, Pakistan is a resource-constrained country, but even its own meager education budget is not fully utilized . There is something else going on that doesn’t allow money from the United States and other donors to be used effectively. Money has not been helpful. What would be helpful is to look at issues that are contributing to the poor utilization of this assistance. It often comes down to program design and implementation strategies. Many of the donor supported programs are not designed with Pakistan’s context in mind. Also there is not much attention given to serious evaluations of mistakes and poor results. Nobody, neither the donors, nor the government, nor the technical experts –and there are no civil society groups– ask why the program failed to deliver results. Therefore, if $450 million hasn’t worked in Pakistan, maybe we should question why it didn’t work before increasing the funding, so the same mistakes can be avoided.
Q: There has been discussion surrounding the polio vaccination campaign in the NWFP and the previous resistance to such strategies by the militants in those areas. In fact, many public health officials were beaten or kidnapped when they tried to implement such programs. What do you think of this phenomenon?
It is complicated and yet very simple. The explanation lies in the overall context of the country, the way these programs are implemented and the history of people’s encounter with the health system. The question to ask is why. Why would people who invest out-of-pocket to buy health care for their children –travel long distances to get it, beat up people who bring it to their door? One reason for these beatings could be that people do not trust the “system.” They have experience that when they needed health care, the system failed them and these very people who are now coming to their villages and houses were not there when they were needed.
The issues are very complex – you cannot just look at it like “these people are mullahs and that’s it,” or just say that “they’re conservative and illiterate.” These are not satisfactory answers.