How politics creates an innovation lag in
Punjab’s health sector

Shehryar Nabi

A startling statistic keeps Ali Hasanain, an assistant professor of economics at the Lahore University
of Management Sciences (LUMS), awake at night: one out of five children in the four poorest
districts of Punjab die from health complications before their fifth birthday.

That’s just one of the many numbers that show how dire health outcomes are in Pakistan. 22
percent of Pakistanis are malnourished due to low access to nutritious food, and that figure doubles
in children. The increased risk of disease and death that comes with malnutrition has given Pakistan
the highest infant and second highest maternal mortality rates in South Asia.

To make things worse, families seeking treatment have a hard time finding a doctor.

A study conducted by Ali Hasanain, Michael Callen (University of California, San Diego), Saad Gulzar
(New York University) and Yasir Khan (University of California, Berkeley) found that nearly 70
percent of doctors are absent during normal working hours.

The research titled "The Political Economy of Public Sector Absence: Experimental Evidence from
Pakistan" is based on data collected from interviews with senior health officials and inspectors,
attendance audits, election data and surveys of Punjab's health clinics through random visits
between 2011 and 2012.

Doctor Absenteeism

Low doctor attendance is an important reason Pakistan’s public health clinics are under-utilised.
Hasanain made this observation while visiting Basic Health Units (BHUs) – the lowest-tier public
health clinics for primary care – during the survey.

“Even though options outside the BHU are not great, you don’t always find a long line of people
waiting at BHUs either,” said Hasanain.

One solution has been to improve doctor inspections through the use of technology. Instead of
using an outdated, paper-based system for monitoring doctor attendance, inspectors would be
given smartphones to feed attendance information to the provincial government, which would
be updated in real-time.

Senior officials can then identify which clinics need to be held accountable, for low attendance

The researchers designed and implemented such a system in collaboration with the Punjab
Health Department.

The study ultimately found mixed results from the smartphone powered intervention. While
monthly inspections of clinics nearly doubled, there was no impact on doctor attendance on
average and outcomes varied across different districts.

The link between politics and attendance

The researchers suspected that politics had a role to play in uneven attendance, so they compared
data from the smartphone-based monitoring system with voting data from the 2008 provincial
assembly elections.

They found that doctor attendance closely reflected the local political scenario. Doctors were 21
percent more likely to be absent in constituencies where one political party achieved a strong
victory. Where competition between parties was higher, smartphone-based inspections show
increased attendance by an average 10 percent.

Interviews with public health officials allowed the researchers to put forth a likely explanation
of how these mechanisms work.

Candidates contesting an election often need the support of prominent community members to
secure victory. In exchange for their support, politicians make sure that these community
members or their relatives are awarded postings as doctors regardless of whether they come
to work or not.

Out of the officials interviewed, 44 percent reported that politicians continue to interfere in their
work in this manner.

In this circumstance, political patronage deflects penalties for doctors who miss work. While
undergoing smartphone monitoring training, an inspector explained to Hasanain how this plays
out in his job.

“He said, ‘you’re giving me this smartphone for monitoring, but it’s useless. I already know who
is not showing up to work, the issue is not that I don’t know who is absent, it’s that I don’t have
the ability to reprimand them, because they have political cover,’” Hasanain recalled.

Another intervention was tested; the data collected through the smartphone monitoring system
was used to generate visualisations that flagged clinics with low attendance to alert senior health
officials, who could then discipline the worst performing clinics.

Flagging improved overall attendance by 27 percent. But again, there was a larger impact in
competitive constituencies while remaining comparatively insignificant in the least competitive.

All of this suggests that while technology-based solutions can certainly make more doctors show
up to work, they can only do so in the right political climate.

Is there a viable solution?

If technical solutions have their limits, can the political problem be fixed?

The results of the study suggest that the key to service delivery improvements may lie in making
politics more evenly competitive.

Since doctor attendance was higher in districts where one candidate did not dominate the vote,
greater competition between political parties could mean that they try to win votes by offering
better policies and services.

As a result, politicians are held accountable by voters based on how well they deliver public
services, meaning doctors who want to miss work would no longer have a political safety net.

Hasanain thinks that since urban politics is relatively competitive and issue-driven, the media
should serve as an educating force to make urban residents care more about the well-being of
residents from rural areas and put pressure on politicians to improve health outcomes across
the province.

It has also been argued that governance needs to be more localised: Rather than having a
centralised government structure in Lahore, enforce attendance at health clinics across the Punjab
whereby doctors should be held accountable by Tehsil or District level managers.

Some contend that the best solution is to reduce risk factors to health such as poor sanitation and
low access to nutrition, rather than starting with the public health care system on its own. This
would prevent the onset of illnesses, reducing the need for public health clinics. There are some
large-scale initiatives addressing this, such as the government’s food fortification program and
the Saaf Pani Company.

But if a poor family is exposed to a hazardous environment and has the bad luck of living in a
patronage-heavy constituency, their first defense from developing a severe illness will likely
remain out of sight.

The writer is a communications associate at the Consortium for Development Policy Research,
a Lahore-based research dissemination organization.

Source:DAWN.COM, February 28, 2017

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