Contents   Editor's Note 1. The Venue   Download

Dr Shaheen Sardar Ali
Reader University of Warwick
s.s.ali@warwick.ac.uk

Editor's note:

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 in 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, 'Who Writes the Budget: A Close-Up of the Politics of Development Projects: Implications for Health Care Delivery, Democracy and Good Governance towards a Human Rights Development Approach', 2002 (1) Law, Social Justice & Global Development Journal (LGD). <http://elj.warwick.ac.uk/global/02-1/ali3.html>. New citation as at 1/1/04: <http://www2.warwick.ac.uk/fac/soc/law/elj/lgd/2002_1/ali3/>

---

1. The Venue

The location of this commentary is the Office of the Minister for Health, Population Welfare and Women development, NWFP. The scene: A host of officers of the Department of Health gathered round the table, Minister chairing a meeting to discuss a circular from the Finance Department asking for the annual budget of the Department of Health. The Finance Minister's memo also lay on the table asking all Ministers to 'take a close and hard look' at the draft budgetary proposals for the coming year before an impending meeting of Ministers on the subject. The question, posed by myself, what I had innocently considered a simple and straightforward one, was the following:

'How do we formulate our annual budget; what are the parameters guiding us in this process and who is involved in it?'

The silence in the room was pregnant. You could almost hear a pin drop. From my little bit of experience in government I had learnt that when a response was not immediately forthcoming, it meant that there was no plausible answer to provide and the silence was the time in which it was being carefully tailored in the minds of the 'government' before being shared with the minister.

I repeated my question. 'Gentlemen,' I said, 'Who prepares the budget in this department and how is it prepared?' Again the telling silence. Any 'sensible' person would have let the question go by unanswered and perhaps at a more opportune moment in time, queried the private secretary to evoke an 'appropriate' response. Not the persistent (read 'stubborn') academic-turned Minister, used to extracting responses from recalcitrant pupils! And especially not now when the honourable Finance Minister was breathing down our necks. The look on my face that meant you will jolly well respond to my question or we can sit here till the cows come home, got the better of everyone. Furtive exchange of glances ensued, accompanied by fidgeting in their seats and elbow-nudging. Finally, one courageous officer cleared his throat and declared in one breath:

'Actually Madam there is very little to prepare. All we do is to look at last year's budgetary allocations and add ten percent on it. That becomes the next year's budget. It is quite easy Madam so you really don't need to worry. Nearer the time, we will give you a copy to look at'.

I could have murdered at that response and happily walked to the gallows, so angry I was at the limits of callousness, nonchalance and disengagement of government in dealing with the taxpayers' money and wealth of the nation. But who could I direct my anger and frustration at? Certainly not these officers huddled round the table, who felt a trifle uncomfortable at being quizzed on what they probably had never considered an issue to bother their heads over? Should I blame institutions responsible for training government functionaries for failing to teach them the 'financial ropes'? But, most of all, was it within the job description of our leadership to engage in an informed process of decision-making when it came to needs of a certain institution, the purpose of which was to provide service to the people? The bewildered look on the face of my colleagues in the Department of Health was indicative of the fact that the question I had posed had probably never been directed at them before by anyone. Or perhaps, the breadth of what the question entailed suddenly dawned upon them, resulting in the anxious expressions of a hitherto carefree group of government officials.

'Right gentlemen; thank you for your information and for being so honest with me. Now shall we get cracking on getting a budget together? We will require certain crucial information before we start. I need all District Health officers to prepare a list of health facilities under their command, complete with personnel, number of patients accessing these facilities and annual budgets broken down under the various heads including salary, medicine and other equipment, etc., And of course, what allocations each facility receive towards maintenance and repair'.

It was easier said than done. I could have asked for the moon and had better chances of succeeding. Ripples of discontent ran through the length and breadth of the Department of Health at what was perceived a useless exercise. As one 'observer' of the new government and the new set of Ministers declared:

'The problem with this lot of Ministers is that they talk too much and write too much. In the good old days, it was all we could do to get the honourable Ministers to even sign on summaries. They simply had no time. Now this lot will not only read all the summaries but also make corrections in them and then write pages and pages, and they can even type and use the computer!'

To me, as a researcher, data collection was the first and foremost step towards evolving a needs based, rational budgetary process. At a simple ethical level, how could I justify putting my signatures on a piece of paper when I was not even aware of how those figures had been arrived at? With finite resources, we simply could not afford to do the customary 'add ten percent' and submit act ever again I hope!

So we set about trying to 'do' a budget with a difference (or so we thought!). When people ask me how I found my stint as Minister, I often respond by saying that no school, college or University could have taught me what these two years in government achieved in widening my horizons and approach to government and governance, people and institutions. I learnt that what we term as lack of resources and 'takleef' from God is actually very human-made and due to our sheer lack of applying our hearts and minds to make optimum use of our resources. We suffer and make our people suffer not because they were destined to lead miserable lives but because we, in our intellectual and physical apathy and laziness fail to apply ourselves to the job in hand. We love to rave and rant about our Muslimness, pray day in and day out, have 'dars' in our homes, offer khairat and sadaqas; in fact everything to secure a place in heaven for ourselves. What we forget is that God up there can see beyond and through these outward offerings to Him, and has one question to ask: What about huqooq ul ibaad? What about service and love to His people on earth?

One cursory glance at the budget figures and it was crystal clear where most of the problem rested. Budgets are classified as 'recurrent' and 'developmental'. A recurrent budget is that part of the budget that recurs on an annual budget and consists of salaries of personnel, maintenance and on-going expenses to run institutions, in this case the various facilities of the department of health. A breakdown of the recurrent budget shows that approximately 90% of the funding is tied up to salaries of personnel serving in these institutions. The government of Pakistan, and certainly of the NWFP is the largest single employer in the country/province. Due to a traditionally under developed and lack lustre private sector, pressure on successive governments has been to act as an employment agency and recruit people left right and centre. For the short term of course, when political leaders are playing to the gallery, as they are wont to, this affords them easy popularity and a quick fix to win the next election as well as please party workers and constituents. But, in the long term, this has resulted in a near paralysis of any effective strategy for a policy of sustainable development in the country. As an appendage to this quick fix mass recruitment into government is the lack of a meaningful accountability process for government employees. That is why everyone wants a 'pakki sarkari naukari' knowing full well that once through the door, they will only come out at the other end with a pension. There is nothing wrong with remaining in office until retirement except that when it means whiling one's time and trying to cream off whatever benefits one can without providing an honest dedicated public service, it costs the country very dearly.

The example of the Basic Health Units (BHUs) of the NWFP comes to mind in paraphrasing the above. Once upon a time, some researchers in some high flown research centre or university dreamt up a brilliant idea of primary health care in developing countries. They developed a blue print of how every 'x' miles, we should build a health facility where basic health care could be provided. Beyond basic health care, if the need arose, the patient would be provided a referral 'slip' to proceed to the 'secondary' health care facility and if there he /she required further specialised care, then a referral to a tertiary institution would be provided. The idea looked excellent on paper as has happened many a time, without much thought, it was adopted, lock, stock and barrel in many countries in transition, including Pakistan. I must add here that one of the reasons for making this look attractive was the accompanying sums of cash to implement this idea.

What transpired thereafter is a tragedy of errors (to partially borrow from one of the titles of Shakespeare's famous plays). Landowners (and a spattering of other people) with the right connections were made rich virtually overnight because suddenly there was a surge to purchase land by the department of health to build these BHUs. Governments thrive the world over on vaguely worded and evasively formulated rules and regulations. This is employed to the advantage of special people. Show me a face and I will show you the rule is an oft-cited saying in government circles. Thus, what resulted was BHUs constructed in the middle of mountains, in the middle of grave yards on the bank of river, miles away from habitation or in the thickest part of a forest! This state of affairs was not confined to the department of health but also 'applied' to the department of education. I remember Gilani Sahib, Minister for Education, remarking one day that he had gone to a school where the building was at one end of the village and the playground three miles away at the far end of the village. When he had queried the reason for this bifurcation of the school he was told that that is where the land was. And after all, the children did need to stretch their legs a bit, so travelling a few miles to the school playground really was no big deal and why was the Minister so appalled?

In many parts of the province, BHUs became the private hujras or deras of the people who had supposedly donated land to government to construct these BHUs. The trade off here was that in return for donating land, one or two of their family members would be given a 'pukki sarkari naukari . Hats off to these supposedly saada dehaatee log who had their maths organised to a point where in return for a few kanals of land, that was anyways lying barren and worth very little, they managed to land permanent jobs for their sons/sons in laws, etc., As later events unfolded they also ended up having the building to themselves as well because government assigned teachers, doctors and other personnel did not bother to come and serve in these back of beyond places. They chose instead to connive with the right persons in headquarters and draw salaries for doing nothing.

How then does one budget for a department where one is not sure of how many health facilities are functional, how many are under-utilised and how many are 'over subscribed and need extra support or upgrading to provide further services. (in government, our vocabulary was enhanced in a curious way and we learnt phrases that we had never quite come across. Gilani Sahib would often say how he could not get his head round these newly constructed words used in bureaucratic channels such as 'up gradation' of an institution or when someone said 20 'bedded' facility and so on!)

I decided that I would do a pilot project and chose district Charsadda to analyse existing budget lines of the department of health. So to Charsadda we ventured accompanied by some of my colleagues who were enthusiastic to try their hands at this new learning initiative. We spent a few day touring the length and breadth of the district and came away amazed and dazed at what we experienced. First of all was the sheer waste of resources both human and material. Every BHU was assigned the following staff: a doctor, a Lady Health Visitor (LHV) a Female Medical Technician (FMT) a Male Technician (MT), a Dai, a Behishti and a Caretaker. The premises of the BHU were built on about 8 kanals of land and included the doctor's consulting room, the LHV/FMT room, a dispensing room, a toilet a store and a small kitchen and verandah. The premises also had a doctor's residence, a LHVs residence and the caretaker's residence. I have yet to see a single toilet for patients functional and where people, travelling from miles around are expected to go when the need arises I s beyond my comprehension. This speaks volumes for the public oriented and people friendliness of our government institutions and service outlets! I came to be known as that minister who always asks about the toilet because everywhere I went, whether it was an office or a hospital, I insisted on inspecting the toilet!

On arriving at the first BHU, I found all the personnel lined up (I have my strong suspicions that there had been a 'leak' about my visit and we found everyone in a state of unusual preparedness!) In a small establishment like a BHU and with an average turnover of 30 patients, I was rather surprised at the number of people assigned. In an attempt to unravel the rationale of having so many people at a BHU, I asked the doctor, LHV, MT and FMT what they did. All of them said that they put a thermometer in the mouth of the patient, recorded the temperature, checked the blood pressure and asked the patient what the signs and symptoms of his illness were. Thereafter, the doctor prescribed some medication. Since a BHU was supposed to be just that a place where basics were addressed, nothing further could be provided in terms of health care. In an ideal world, the MT, FMT and LHV were supposed to be supporting the community in access and provision to basic health care including ante natal care to pregnant women, vaccination and routine immunisation to children and pregnant women. But in a real world, the LHV and FMT were at loggerheads with each other and vied with each other to catch patients within the community. This resulted in fewer women and children receiving any real benefits from a BHU and they increasingly relied upon private hours of these health personnel for their health care needs. The doctor, who was supposed to be the boss and line manager of all health care services provided at the facility was anything but a boss and often at the mercy of these support staff who had strong connections within the community. I have personally had to intervene to unsuccessfully support a doctor to carry out orders of the health department where 'powerful' LHVs and FMTs have defied not only administrative orders but also orders of the court.

The functions and training of the LHV and FMT are identical except that FMTs do not have midwifery training. One major outcome of trying to rationalise budgets was to withdraw FMTs from certain BHUs and assign them as nurse auxiliaries at facilities where they were required to provide cover due to the acute shortage of nursing staff. At least four dozen FMTs were also sent to train on the midwifery programme to enable them to come at par with LHVs so we could extend cover to more facilities.

Another interesting find of the Charsadda 'adventure' was to discover that our health planners, budget makers and implementers of policies were oblivious of the ground realities. Under some loan that we would have jumped to catch, numerous X-ray machines were acquired and promptly deputed to health facilities round the province. X-ray technicians also existed as a cadre within the department of health but in assigning either the machines or the technicians, no one bothered to 'match' the two. Thus my field visits detected a strange situation: These were health facilities where x-ray machines sat snugly in their containers, unopened because either there was no electricity or no technician and another set of facilities where there were no machines but technicians were duly assigned who sat in the sun or the shade, depending upon the weather, and twiddled their thumbs. X-ray films were budgeted for to non-functional x-ray machines and no one ever noticed the discrepancy because no one ever bothered to go through the fine print of the budget with a fine comb. As a result of the field visits, we developed a policy of retraining existing personnel to become x-ray technicians and anaesthesia technicians. Hopefully this will have been followed up and we would by even a conservative estimate have at least 2 dozen machines in operation resulting in saving of thousands of rupees of patients.

People research and write a lot about the weak periphery of the department of health. The role that people like myself and other in position of decision making and implementation play in contributing to this weakness is evident from a few glaring features of our planning processes. Every year we advertise to train specialists as well as technicians. How do we assess what specialisms to advertise? Your guess is as good as mine or the person walking past the newspaper stand! As a result of a thoughtless or maybe too thoughtful a policy, we have ended up in a virtual lack of crucial and life saving specialisms

How do we prepare our Re-writing the budget; recurring/developmental. (The politics of development projects. E.g., Buner, Tank. DHQ Abbottabad. Tangi etc., Capacity to spend. Monitoring the ADP. Needs based budgeting cf. Charsadda pilot project. Rehabilitation/Reclamation' of assets. Shifting the development paradigm?).

For the other parts in this series, please see Part 1 and Part 2.