Reforming the Health Sector in the NWFP: A Nostalgic View From (?) Afar
Dr Shaheen Sardar Ali
Reader of Law
University of Warwick
This commentary is being published as part of the open forum on Law, Social Justice and Global Development (LGD). It forms a part of three commentaries that have been published in this issue and contextualises the experience of an academic in the governmental processes. Readers are welcome to send in their comments and reviews to the author and/or the editors of this journal. Selected comments may be published subject to the editorial pen. Please send your comments to Manish Narayan.
Keywords: Human Rights, Health Services, Gender, Development, Budgetary Processes, Governance, Human Rights.
This is a commentary published on 8 November 2002.
Citation: Ali S, 'Reforming the Health Sector in NWFP: A Nostalgic View From (?) Afar', 2002 (1) Law, Social Justice & Global Development Journal (LGD) 2002 (1) <http://elj.warwick.ac.uk/global/02-1/ali1.html>. New citation as at 1/1/04: <http://www2.warwick.ac.uk/fac/soc/law/elj/lgd/2002_1/ali1/>
Sitting thousands of miles away in my office at the University of Warwick, England, on a bleak Sunday afternoon, I stare down at the brick courtyard with its two barren trees, a sculpture, and a few bicycles parked in the shed. Bare trunks of the wisteria creeper clinging to the wooden poles present a stark contrast to its summer glory when lush green leaves and bunches of lilac blooms form a pleasant shade. But, this scene simply blurs and fades into oblivion, for my eyes see views very different ... . Skies, blue and radiant against the stately backdrop of the Khyber Mountains, overpowering and defiant. The bougainvillea plant, a riot of colours magenta, red and orange climbing tenaciously over walls of houses and along the Hayatabad road! The yellow 'motia' will surely have heralded spring with the pale pink blossoms making a more subtle statement. All this and then my gaze focuses on the teeming millions making their way as best as they can, through the unruly Peshawar traffic, the blaring horns, the concerted effort to jump over the dividing fence on Jamrud Road rather than use the underpass to get to the other side of the road. I can almost see the frantic, frustrated look on the face of the traffic constable gesticulating impatiently towards all and sundry in an unsuccessful attempt at ordering this mayhem!
But these images and imagery are for those who can afford the luxury to sit back and admire nature's bounty choosing not to see and feel thorns among the roses and the misery of the downtrodden among the more fortunate members of the human race. Does this not read almost like the famous story of Marie Antoinette of France who, in her moments of wealth splashing and partying was asked how she could be so careless with money when her people had no bread to eat. To which she retorted, albeit innocently, then why don't they eat cakes! That statement may have hastened the end of the monarchy and ushered in the French revolution. The purpose of my statement invoking the scenic beauty of Peshawar was simply a prelude depicting a deep yearning for my homeland and the first step towards sharing my thoughts on policies and decisions adopted in the Department of Health, that impinge very deeply on the life of the common person in the street.
It is never easy to extricate oneself from a job that virtually consumes you physically, mentally and emotionally - in short - a job that for me, was truly a labour of love! I was an academic of 25 years standing who had taken two years out from teaching Law to become a Minister in the Government of the NWFP with the understanding that this was a purely temporary phase of my life and I would return to my 'former' life. Why then was deciding to exit so traumatic? Perhaps it was the very nature of this challenging brief that totally immersed me for two years. Or, was it the reform process I had initiated, fragile and vulnerable like a little fledgling sapling needing tender handling and passionate nurturing that invoked a feeling of guilt in me making it impossible to let go? In all this upheaval, one thing was adequately clear i.e., that long before I realised it, I was irrevocably converted from a legal academic into a 'health' person. My detractors, who had always pointed out that I was NOT a medical doctor and so what business had I to become Health Minister, will be disappointed to learn that this conversion will remain with me for the rest of my life, and so, whether they like it or not, the department of health has gained a foot soldier and ally for keeps!
I sit here reflecting upon my life and work as Minister for Health, Population and Women Development in the NWFP in an effort to enumerate what the most prominent images of the past two years are, and why these haunt me incessantly? Not the glorious mountains that dominate the skyline of Hayatabad, nor the beautiful flowers and trees that line the streets and homes of the wealthy. I was privileged to see a very different world, a world that made me acutely aware of my own inadequacies as a human being, how fortunate and blessed we are and the responsibilities that we owe to society as recipients and beneficiaries of these blessings.
I see a woman in a white 'shuttlecock' burqa walking towards the Basic Health Unit (BHU) of a far-flung village in the bitter cold of January, making her way through a muddy field with a baby tucked inside her burqa. She approaches the BHU where I walk towards her and fondle the rosy-cheeked child with a twinkle in his eye. The child responds by holding out his hand to me and kicking his legs and in the process I see little bare, feet, red with cold peeping through the mother's burqa. I touch the little feet and find them ice cold. The mother looks at me and then quickly says: 'Actually he does have a pair of socks. I washed them last night and hung them up to dry so he could wear them this morning. But it rained last night and so the socks got wet because I forgot to take them off the washing line'. I virtually froze with shame. How could we justify our existence when this poor little soul had only one pair of socks to keep his toes warm while some of us have dozens of clothes with loads to spare and yet want more and more all the time.
Another image that has never left my 'inner' eye is the young woman who I met in the Mental Hospital in Peshawar. She appears composed and is neat and tidy in her outward appearance. I ask the doctor on duty what her problem is. I am told that the girl belongs to a well to do family and suffered some problems necessitating her admission to the mental Hospital. She is fully recovered now and we have been calling her family to come and take her home. The family keep making excuses and only yesterday they have clearly refused to take her back saying that this will give them a bad name and people will say that you have a 'mad' person in your household. The young girl lies abandoned by her loved ones and the family that we like to flaunt as a haven of security and protection, has turned its back on her. The doctor feared that living among mentally disturbed patients is most likely to make this recovered patient relapse. Also, from past experience of doctors here, it appears that this patient will be banished to remain here for the rest of her life. Could I do anything to alleviate her suffering? Who is willing to accept such people back into the societal fold and help her integrate? Whose obligation is it? That of the family of who she is a member but who have now abandoned her, the community that acts as the guardian of peoples' morality, sermonises about how we should hold each others' hand and yet turns its back on people who suffer from any disability? Or, should it be the government that should provide safety nets for people such as the girl at the Mental Hospital who simply fell through the cracks of the social system?
As an academic accustomed to public speech and interaction, I loved the public meetings and discussions with people in the field. But what shook me was the intensity of my own emotions evoked by the moving welcome given to me by people of one of the most backward areas of the country, Loya Agra, Malakand Agency. The Political Agent of the area, an enthusiastic gentleman, had arranged for a three day medical camp for the area and wanted my presence to inaugurate it. He appears to have confided his concern at whether I would be willing to travel to the back of beyond, a schedule that entailed at least 6 hours of travel from one mountain to the other and to an area where there was little to 'see'. My staff indicated that I was more than happy to undertake that arduous journey and so we ventured into Loya Agra. Hundreds of people, old, young, men and women and children of all ages had come out to welcome me. I suspect that the large turn-out also had something to do with my being the first woman minister they had every set eyes on and therefore I was a sight unto myself! The articulate stage secretary and the elder who presented their welcome address drove me to tears. The gist of their presentations was: Even if you have nothing to offer us, we treasure your presence here and consider this an end in itself! All this was of course said in a very moving and poetic form of expression and when I rose to speak, my emotions got the better of me and I broke into tears. I did not realise the impact it was to have on the audience because before long, we had everyone holding hankerchiefs to their eyes, including myself and having a sound weeping session together. I thought to myself, how devoid of hope can people get and how low can their expectations fall, to aspire simply for and be content with a visit from a government functionary? I was, apparently, the first minister who had visited this area in 54 years of the country's existence!
Going further down memory lane, I find myself in a village in Hazara. I had dedicated the summer of 2000 to revitalising the Lady Health Workers programme and went from house to house enquiring about the performance of the Lady Health Worker (LHW) and talking to people about the importance of this basic cadre of health workers. Being a woman was a huge advantage because all I had to do to gain entry into a house was to knock on the door and ask if they had a dog or not! If the answer was in the negative, I would venture straight in and start a conversation. In a village near Havelian, I went into one of the houses and was very impressed with the health worker. A middle-aged widow who said she wanted to earn an honest living to bring up her children. Her register was meticulously maintained and she knew exactly what her job description was. But what impressed me most was the neat and clean house she lived in. She felt it was part of her professional 'face' to act as an example for her clients. Her love for plants and the large variety she had collected in her small kutcha house was remarkable. I have to admit that I detracted from my 'health' ministerial visit and we started chatting about the plants, what soil they thrived in when they were in bloom and how to multiply them. I distinctly remember the surprise on the face of the village Imam and the local men of the area when they were told that the Health Minister was inside that little house talking to the health worker. Our visits were mostly impromptu and surprise to ensure a true reflection of the state of the health services and its providers and the impact, at least for the coming months, was positive.
A village on the outskirts of Mardan next comes to mind. A new initiative in managing childhood illnesses was being floated and a study to test the ground reality was fielded in the area. I sprung a surprise on the DHO/ADHO by saying I wanted to take the questionnaires and double check the responses in the village where the data collection had taken place. He did inform me that I would have to walk through dusty fields and lanes, jump over nallahs, etc, but when this declaration failed to daunt me, he threw in the gauntlet and led the way. As we were going through the village I saw a couple of women wearing a grey kameez and white shalwar and a very professional demeanor. Who are these women I asked the officers accompanying me and to my pleasant surprise was informed that following my three month revitalising visits, the lady health workers had become so encouraged that they voluntarily made themselves a uniform and wore it when they were on their visits in the community. The dynamic Provincial Co-ordinator of the programme had provided them with ID cards as well which they could display when on field and hospital visits.
I also have to share what I consider one of the highlights of my life as a Minister. My trip, alongside the Minister for Education, Syed Imtiaz Hussain Gilani, to a village called Karab Kalay in FR Bannu. The road, beyond Bannu, if one can call it a road, was a dry river bed, and for miles and miles there was no sign of habitation. But then, as if in the middle of nowhere, we arrived at this magical village where 103 years ago, a girls' primary school had been opened. The grandson of its founder had insisted that we come and commemorate the occasion. This was a village where there was 100% literacy and the women and men were thirsty for more knowledge and places of learning. Unfortunately, red tapism had never allowed this pioneering village to advance beyond the usual half-hearted upgrading from primary to middle and then, high school. Neither had anyone in position of authority ever visited the place and so two ministers in one day was a bit of a mouthful for them. The entire village was treated to a meal and it struck me how little it takes to lift peoples' spirits and make them happy. For us it was a dusty, rumbling, uncomfortable meandering drive through nowhere and back to Peshawar, but to the people of Karab Kalay, it was a great moment. It was memorable for them not because we had given them anything in material terms, but the fact that we took the time to share their moments of glory! When some segments of our society argue that people in rural areas are hesitant to send girls to school, Karab Kalay completely belies that position because for one hundred years, every single girl born in that village has been to school.
But what really made our eyes moist, and Gilani Sahib and myself remarked on it later, was the boys school on the way to Karab Kalay. The boys had come out to greet us and we took a turn round the school to meet the children. There were no benches and tables for the pupils and the state of abject poverty of the children was apparent from the state of their shoes that they had taken off before entering the classes to sit on the floor. I could have stood there for hours looking on the broken chappals, tied together with a piece of string, shoes that was only half there, a boot with no laces and so on. Yet the sparkle in their eyes when Gilani Sahib asked them to read to us from their English reader reflected the hope and aspiration of youth that time and disappointments had not dampened. Imagine our despair when the headmaster took us past a well that had been in disrepair for years and informed us that the children had no drinking water and of course, no toilets.
A final glimpse that I want to share with you, is about a Rural Health Centre (RHC) on the fringes of District Charsadda. Situated on the outskirts of the village, on a dusty, kutcha road and non-descript landscape, we drove into this freshly white/red washed building, with lots of orange marigolds lining the little front garden of the RHC and dozens of citrus trees adding bright colour and character to the otherwise forlorn surroundings. An enthusiastic young doctor who introduced himself as the incharge was responsible for this little oasis of a facility. The daily outpatient figure averaged at 500, the 'lived in' and used in look of the facility was clearly visible. In a few minutes, I was inundated by a group of villagers who were curious to know the purpose of my visit to this seldom visited place. They immediately made their views regarding the facility and its staff known and said it was the best thing that had ever happened to their poor area.
A question that always bothers me is: where does one 'buy' commitment, dedication and honest performance of one's duty? Governments can construct buildings, furnish these with equipment and inaugurate health facilities to their hearts' content, but it is only people that breathe life into these buildings. Even the best facility will fall into disrepair and people will not approach it for services if no health provider is present or intermittently available. The young man from our RHC taught me this lesson; he was aware of his limitations in terms of what his facility had and did not have, he was short staffed and all the rest of it. But, he soldiered on with what he had and what he could deliver and the community recognised that and came to his support. They collected thousands of rupees to spruce up the place. But how aware were we in government, of such precious professionals who were carrying out their duty with missionary zeal? Did the abstract and impassive face of government have the means to sift these gems and applaud their services? Had we not, unthinkingly and conveniently, undermined and unvalued the work of these service providers by asking them to stand in the same queue as ones who simply went into their workplace to collect their salaries and spent the rest of the month conniving with 'relevant' people to continue this practice?
I could go on and on because the images that I cherish are numerous and precious and as vivid today as the day I first experienced them. But why I want to share them is not simply to tell a good story. Each and every one of these narratives has a deeper meaning to it and holds the key to the manner in which we engage in governance, and reflective of how governance is viewed both by those in authority and the people being governed.
After a period of initial shocks and initiation into the 'real' world, I stopped being amazed at the lack of ethical norms among health service planners, implementers and providers because we have, over the decades, slipped into an abyss of cynical despair and hopelessness. The worst predicament of a nation is when her people forget to trust and nurture hopes for a better tomorrow and I shudder to state that we appear to be on the brink of such a condition. What therefore surprised me were the handful of idealistic men and women who rallied around me, stars of hope twinkling in their eyes, giving all they had, to restructure and reform the health service provision of the province. It is this group of colleagues and friends in the Department of Health that lead me to dream on and hope for a brighter future both for the professionals involved and the people who we are meant to serve. My heart goes out to all those in my team, who worked day in and day out to help me put a reform agenda in place, and most important of all, the people of the NWFP who I set out to serve. I cannot thank God enough for having afforded me this invaluable and priceless opportunity to make my very humble contribution towards evolving a culture of good governance and committed leadership. To the new Minister for Health, Dr Mehrtaj Roghani and Dr. Rubina Gillani Adviser to the Governor on Health, Population and Women Development, both very dear friends of 26 years, my heartiest congratulations and all my prayers and support. Their appointment is really a miraculous move towards sustaining those fragile plants of reform, so lovingly sown by us as a team. Thank you for being with me through all the ordeals. Last but not least, my gratitude to the Captain of the ship, His Excellency the Governor of the NWFP, and my cabinet colleagues, for the wonderful working environment, encouragement and autonomy in my humble attempts at reforming the health sector in the NWFP. No matter where we are, the close-knit family atmosphere in the cabinet has created lifelong relationships of friendship. God bless you all!
To be continued.
For the next part in the series, please see Part 2.