Strengthen the units

Published: October 16, 2018
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The writer is a Howard Hughes Medical Institute professor of biomedical engineering, international health and medicine at Boston University. He tweets @mhzaman

The writer is a Howard Hughes Medical Institute professor of biomedical engineering, international health and medicine at Boston University. He tweets @mhzaman

The winds of austerity can be quite brutal. Important public support programmes are put on hold, social services can be disconnected and large holes are poked in the safety nets for the poor. There is a good chance that important programmes in education, research and health may be considered frivolous. While wasteful spending should indeed be curtailed, austerity shouldn’t mean that under the guise of belt tightening we sacrifice our future at its altar.

Instead, this is an opportunity to restructure and do what is well-understood among experts in health and education to be a balance between saving our present and investing for the future. The sound approach, at this juncture, is to focus on strengthening the basic units of our social welfare programmes. A system with strong basic elements is much more resilient than the one that expands rapidly and uncontrollably.

Shocks to the system, whether due to economic turmoil or outbreak of natural disasters are likely to have limited impact if the basic units are robust. From a strategy perspective, this would mean to limit expansion, but instead improve the structure, efficiency and quality of what already exists. That is, when it comes to public health, strengthen the basic health units (BHUs).

When it comes to education, strengthen the basic units of accessible education, and when it comes to research, strengthen the units of research. From a practical standpoint, this would mean three basic things.

First, focus on evidence and not impulse. This means that while there may be an impulse to blame the former administrations for all problems, a more prudent approach would be to look at what is working and what is not. Some programmes, in health and education, by  previous governments may actually be functioning reasonably well, and ought to be continued. Others may need some tweaking and some others may need to be scrapped altogether. A nuanced and inclusive approach is also likely to bring the provinces together and not antagonise them through inflammatory rhetoric.

Second, building a plan that lasts beyond the first few months or even first few years. Once again, the impulse may be to change things overnight, or to make bombastic (and sometimes bizarre) claims. Instead what is needed is a plan that is both workable and sustainable. This may mean to have somewhat modest goals that pay dividends over years and generations, and not just the ones that last until the next impulsive decision.

Third, and perhaps the most important pillar of policy has to be ensuring consistent quality. The central metric by which all initiatives, and system strengthening must be judged is not expansion or access but quality. Two recent global initiatives, one carried out as a Lancet Commission and the other by the US National Academies (and chaired by our own Dr Sania Nishtar) have emphasised this point. While their focus has been on health, the broad principles apply to other sectors as well.

The resilience of our basic units of education, research and health, must be able to provide quality services and generate quality products, in all scenarios and at all times. While an emphasis on quality control is not particularly flashy, waste due to inefficiency and poor quality continues to weaken our system from within. Ensuring quality in services is not just an ethical responsibility, it is also smart policy both from the perspective of building trust and from controlling waste in the system.

Recognising that the road ahead is rocky does not mean that we give up on the future, distant as it may seem. Instead, it may be an opportunity to build trust, even with those who we may disagree with, and create a system that is capable of handling internal and external tremors.

Published in The Express Tribune, October 16th, 2018.

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