Quality saves lives
Accrediting hospitals in Pakistan will lead to a better standard of healthcare
By Dr M Javaid Khan
The Federal Ministry of Health has recently developed quality standards for accrediting hospitals to improve the value of healthcare -- an initiative that deserves due commendations. The significance of the plan is evident from the fact that throughout the world 30-40 percent patients do not get treatment of proven effectiveness; 20–25 percent patients get care that is not needed or is potentially harmful. Even in countries like the United States, preventable adverse events are a leading cause of death. The results of two studies show that as many as 98,000 Americans die in hospitals each year as a result of medical errors. Deaths due to preventable adverse events exceed the deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297) or AIDS (16,516). This should be an eye opener for developing countries like Pakistan. 

As a general rule I do not subscribe to essentialist characterisations. So, for example, I do not believe that the 'West' or 'Islam' are exclusive concepts; those who insist that they are, whether they hail from the 'West' or from the lands of 'Islam', do so only for self-serving objectives. The 'Islam' conundrum is perhaps more difficult than the 'West', because many Muslims do believe -- in the religious sense -- in the mythical notion that there is an 'Islamic Ummah', which is by definition exclusive. Nevertheless as we in Pakistan found out in 1971, religion is but one component of cultural identity, and does not necessarily take precedence over any other component.

With this brief caveat in mind, I want to draw attention to the deep underlying ritual caste discrimination that exists in 'Islamic' Pakistan in light of the anti-Christian pogrom that took place in Gojra some days ago. Public comment in the days following the looting and burning of Christian homes by mobs has rightfully condemned the complicity of the local police and administration, and raised questions about the participation of local PML-N cadres in the violence and called for serious debate over the role of religion in the public sphere.

My observations here are with reference to the last point. Many 'Islamic' scholars assert that there is no such thing as 'caste' in Islam. It is true that Islamic scripts do not invoke social institutions such as caste, whereas the Prophet himself attempted to dismantle hierarchical structures, slavery foremost among them. But as I suggested above, it is important to realise that 'Islam' in practice is greatly influenced by local culture, which in our case, is a culture in which ritual caste division are widespread.

So, it is a well-known fact that the Sufis who were responsible for many conversions in the western and eastern parts of India attracted many lower castes, including untouchables. Islam to the scheduled castes in the subcontinent represented a means of social mobility by virtue of being an ideology of relative equality (at least in comparison to Brahminism). Thus a majority of converts to Islam were from the lower orders of society.

This did not mean that caste distinctions disappeared with the advent of Islam. Indeed they remained very much intact, and in areas in which Muslims became a majority, they were articulated in different ways to areas in which Muslims were in minority. The Christian missionaries who accompanied explorers and profiteers as part of Britain's great colonial adventure in India then went onto convert many of the same lower orders of society that remained subject to injustices even after becoming Muslim.

Christians in Pakistan are one of the most discriminated against minority communities anywhere in the world. A substantial number are treated as untouchables, both in rural and urban areas. Even someone who is relatively unfamiliar with Pakistan's urban sociology knows that there are a large number of Christian katchi abadis in all of Pakistan's towns and cities and that the majority of the residents of these 'Christian colonies' are sweepers in municipal corporations, private offices and domestic homes. Why is it that Christians form the vast majority of the sweeper workforce?

Because in today's 'Islamic' Pakistan, Christians are still subject to unrelenting caste discrimination. Muslims as a general rule do not marry Christians, they refuse to eat or drink from the same utensils used by Christians and they are even wary of shaking hands or making physical contact with Christians. Muslims refuse to take up jobs that require them to clean toilets or sewage waste. Christians are confined to taking up these jobs, generation after generation after generation. These are classic indicators of ritual caste discrimination, no less damning than what is found in 'Hindu' India.

After the unspeakable crimes in Gojra, no Islamist organisation has come forward to condemn the violence. Not one. Presumably Islamists think that such violence can be condoned, even encouraged. Neither Islamists nor the secularists that run this country have ever acknowledged that Christians (and for that matter a whole host of other minority communities) are subject to all sorts of discrimination, including caste-based. Those who run this country find too much solace in the myth that 'Islam' is an answer to everything and can be invoked at will to explain anything to actually confront the reality of social exclusion in our society.

I do not think it is wrong to suggest that many ordinary Pakistanis who consider themselves to be upright and decent human beings also -- consciously or otherwise -- believe that there is no such thing as caste discrimination in our society. 'Islam does not allow such things so how could they possibly exist?' is the refrain. The well-educated segment of society in particular tends to be very dismissive of social ills, some of them refusing to accept that Muslims could possibly adhere to what they consider to be 'Hindu' customs, others simply contemptuous of the 'common hordes' entirely, habitually noting that such practices are to be expected an 'illiterate' society.

The Gojra incident, like Shantinagar and so many others before it, should give rise to much soul-searching. But we should not be satisfied with the usual tokenisms that cover up the deeper conflicts that exist here. In returning to where I started I do believe that there is somewhat of a shared complex in the Muslim world about being different, a self-pity that permits us to overlook our excesses. In some ways it is a collective psychology that compares to Israel's Jews, who continue to conceive of themselves as constantly embattled, fighting a hostile world. Most of the world considers Israeli Zionists to be tyrants who are depriving Palestinians of their basic human freedoms. It is worth thinking how others look at us when we -- and I say we because there was complicity on the part of a large number of people -- loot and burn Christians in Gojra.

I maintain that Muslims are not necessarily unique in that sense, that they have as many differences as they have similarities. While many Muslims were looting and burning, many others were helping their Christian friends and neighbours escape from the mob. This is why insisting that virtually everything in life boils down to Islam is a shortcut to confronting difficult questions about who we are, where we have come from, and where we are headed.

The auditorium was full of women from far-flung, poor localities of Karachi. One of them plonked herself next to me in the second row along with her daughters, a toddler and a six-year old. A gigantic banner featuring a photo of the late activist Nirmala Deshpande formed the backdrop to an array of speakers from India and Pakistan seated behind a long table on the platform. "PROMOTING PEACE IN SOUTH ASIA AND REMEMBERING NIRMALA DIDI DESHPANDE," it read.

Mumtaz, the young Pahstun mother next to me, had studied up till the eighth grade, unlike most of the other women present. The toddler nuzzled against her to breastfeed from time to time.

The speakers included prominent Urdu writer Zahida Hina, peace activist and educationist from Lahore Syeda Diep, parliamentarians from the PPP and MQM and Indian activist Sandeep Pandey from Lucknow, journalist Jatin Desai from Mumbai, and Kavita Srivastava of the Peoples Union of Civil Liberties (PUCL) from Jaipur. Two other Indians weren't given 'clearance' from Islamabad in time for the visit, meant to further the aims of a joint signature campaign for peace launched earlier this year.

Mumtaz and the other women, mostly wives of daily wage labourers, had been brought there by various 'bajis', women activists working in their areas. "I don't understand everything they're saying," Mumtaz told me, "But I know they are talking about the need for peace between India and Pakistan. That is what we all want."

Her immediate concern was to feed her family. "Maybe if these two countries stop fighting, our lot will improve," she said optimistically.

"Let the people meet, all other matters will sort out," a cyclist told Sandeep Pandey and other peace marchers who went from Delhi to Multan in 2005, demanding that the governments of India and Pakistan resolve all matters of dispute through dialogue.

Such basic wisdom is at odds with the justifications for continued animosity presented by 'intellectuals' on either side of the border. "India/Pakistan wants to destroy us"; "Stop appeasing India/Pakistan"; "There is no point in talking to them".

If we listen to this babble of voices whose sole aim seems to be to present their own country's case as better than the other's, we'll never get anywhere. There is an old saying in our part of the world, "Taali donon haathon se bajti hai" -- it takes two hands to clap.

Let's stop these blame games and accept that there are problems on either side -- of varying degrees and natures, and try and understand the complexities of the problems.

Those with access to the Internet have increased the potential for such understanding. But because we're not used to talking to each other, the un-moderated exchanges posted on blogs are often crass and offensive. Direct interaction involving basic civility and an open mind is more meaningful.

Some time back, a Mumbaikar emailed saying, "Frankly, with Pakistan itself in such a mess (Lal Masjid, Swat valley, Taliban, regular suicide attacks and of course the numerous Muslim organisations ranting about Jihad), do you really feel safe in your own country? And the most amusing thing is when Pakistan tells that India is its enemy number one. Wait for a few more years, am sure the Taliban will take over Pakistan. And what pains us, is what did we do to Pakistan? Kargil was Musharaf's misadventure."

I replied, yes, Pakistan is in a mess, due largely to the continual disruption of the political process, with no democratically elected government being allowed to complete its terms. "This is the biggest difference between India and us, and what I most envy about your country".

Still, women do get around here too, carry on with their work and their lives. And at least elements within Pakistan's establishment no longer consider India as enemy number one.

Kargil was indeed Musharraf's misadventure. Many of us spoke out against it (we're labelled as Indian agents). Pakistan's military must be accountable and answerable to elected civilian governments. This will only happen if the political process is allowed to continue.

Rocky as politics in Pakistan currently are, with a floundering democratic process, it is only more democracy on a sustained and continuous level that will in the long run yield positive results.

The writer is a journalist based in Karachi -- beenasarwar.wordpress.com

The Strategic Trade Policy Framework 2009-11 has recently been announced by the Ministry of Commerce. Initial reactions about the trade policy are mixed. Some analysts and stakeholders have termed the framework a welcome step which shows a medium term perspective for a structural transformation of the economy. However, there are others who claim that the framework is anything but strategic since it does not show a radical break from the past. It still carries the baggage of export-led growth of previous Rapid Export Growth Strategy (REGS) followed by the Ministry and did not prove to be successful.

The biggest danger, some experts argue, lies in not accepting the scale of the problems that both the global and Pakistan's economy faces at the moment. While there is a global recession and consumption is not picking up to the scale which can recreate 'trade an engine of growth' for developing countries, too much emphasis on external trade than domestic commerce is being criticised. It has been mentioned that the economy needs to focus on increasing the size of domestic demand market through expansion of wages (i.e., creating more buyers for consumption of local brands) and sectoral articulation for backward and forward linkages of local small scale and large scale industrial set-ups.

Notwithstanding, in the trade policy, the Ministry has set the export growth target of 6 percent for 2009-10 and 10 and 13 percent for each of the successive years. A casual look at the results of REGS makes it clear that Pakistan has actually seen growth in imports much faster than exports which is manifested in the increasing trade deficit. At a certain level, the basic assumption of trade strategy, which the officials of the Ministry of Commerce have been following, stands challenged. They based their big-bang tariff liberalisation strategy along with kicking away the industrial policy design on the assumption that in order to increase export Pakistan needs to remove import barriers and become a neoliberal economy. This assumption needs a thorough revision with the help of growth and development theory rather than trade theory.

In fact, the trade deficit, which Pakistan is witnessing has similarities elsewhere as well. A recent study by famous economists Amelia Santos and A.P. Thirwall shows that liberalisation in 22 developing countries stimulated export growth but raised import growth more, leading to a worsening of the balance of trade and payments. They argue that despite taking all measures such as removing anti-export-bias, import control, including non-tariff barriers, and exchange rate distortions, liberalisation raised export growth by some 2 percent and import growth by 6 percent with the result that trade balance worsened by 2 percent of GDP. Most astonishingly, their research finds that this has constrained the growth of output and living standards. This means that the findings have important implications for the sequencing and degree of liberalisation for Pakistan as well.

If we look at economic liberalisation processes in Pakistan, then the average tariffs seem to have fallen sharply during the last two decades. These were 120 percent in 1985 and now stand at around 12 percent in 2007-08. The reduction in tariffs also coincides with increase in trade deficit. For example, as compared to the trade deficit being at US $ 1.2 billion in 2001-02, it has reached around US$14 billion in 2008-09. Therefore, it seems that Pakistan has to rely more on private income flows to finance the deficits since reallocation of human, financial, land, and technological resources is not easy and cannot be abrupt. However, other than the remittances, there is a slowdown in foreign capital inflows and investment as well. The total investment fell from 22.5% of GDP in 2006/07 to 19.7% of GDP in 2008/09. In fact, private investment has fallen each year since 2004/05, from 15.7% of GDP in 2004/05 to 13.2% of GDP in 2008/09. These indictors put a question mark before many targets of the trade policy.

In addition, if we look at the growth prospects, the government forecasts that the economy will grow by 3.3% in 2009/10, with growth rising to 4% by 2010/11. While, the agricultural sector is expected to grow by 3.8% in 2009/10, the manufacturing sector by just 1.8% and the services sector by 3.9%, the prospects of a turn-around in production for exports seem not very promising.

According to the Economist Intelligence Unit report on Pakistan, though there has been some form of product diversification in Pakistan with 25% increase in food exports and good performance on cement sector; textile exports continued to decline, falling by 9% year on year. However, rice has shown around 8.2% increase in exports. An interesting development is that engineering sector exports have shown increase of around 26.1%. Therefore, emphasis of the trade policy on engineering sector revitalisation and support must be welcomed though performance monitoring has to go side by side. The use of Pakistan Institute of Trade and Development resources is a good sign of linking research with policy and planning.

However, areas of concern lie in shift of the textile sector to lower value-added production. Data shows that exports of raw cotton grew by 40%, but exports of readymade garments fell by 14%. This deterioration of competitiveness should raise some eyebrows somewhere and such downside risks have implications for longer-term stability of the balance-of-payments position, argues the report by the Economist. India, a major competitor of Pakistan in the textile market, is providing subsidies on textile exports with massive incentives and as a result the Indian textile sector growth rate is 11.6% while Pakistan circles around 3 to 3.5%. The argument is not that Pakistan should also provide subsidies but actually it needs to conduct serious research earmarking priority sectors for product differentiation and also on how the use of subsidies and other incentives should be monitored leading to both production and productivity growth. The need to improve practices and vigilance regarding Afghan Transit Trade is as important as ever for the lifeline of our textile sector.

It is worthwhile to mention that Pakistan has slipped 9 points downwards on the Global Competitiveness Index which listing 134 countries and Pakistan stands at 101 now. The deterioration has been in all of 12 indicators which the index uses to analyse performance showing financial market losing much more. It also shows that the country is poor in higher education and training where it stands at 123 in the comity of 134 nation-states and not so surprisingly the labour market efficiency is low also with standing at rank 121.

While establishing new indicators for performance for monitoring, the strategic framework claims that "by 2012 the competitiveness ranking of Pakistan will improve from 101 to 75". This is easier said than done while looking at the absence of a 'national system of innovation' which connects the triad of education, industry, and policy.

Last but not least, apart from being a strategic ally and a good friend, Pakistan should learn from China and the USA. Looking at the global recession and fall in global consumption which has impacted the trade balance of China as well, the countries are stimulating local production and consumption. 'Buy America' is one instance. In fact, the 7.9% increase in GDP for China will come from increase in domestic consumption which means that it is seriously increasing linkages between local production and consumption. What Pakistan needs is, to make the framework as success, focus much more on domestic commerce and build local brands, wages, production, consumption – in a nutshell a facilitating social and physical infrastructure for economic development since trade is a collective action of an economy and not only about tariff and subsidy manipulations.

The National Finance Commission (NFC) has recently been reconstituted. Headed by the federal finance minister, it will comprise of the four provincial finance ministers and one non-statutory member from each province (total strength being nine). The NFC will make recommendations with regard to sales tax on services as well as increasing fiscal discipline both at the federal and provincial levels. However, the most important question before the Commission is how to distribute the national pie among the federation and the provinces in a way that is satisfactory both economically and politically.

Being federal in character, the constitution of Pakistan distributes powers --legislative, executive and financial -- between the central government on the one hand and the provinces on the other. The constitution has set up different bodies to administer relations between the federation and the federating units. Centre-provinces financial relations are institutionalised in the form of the NFC. As in case of many other federal states, the federal government in Pakistan collects most of the revenue receipts and passes a portion thereof to provinces, which distribute a portion of the revenue among local governments.

The NFC makes recommendations to the president for distribution of tax revenue between central and provincial governments and subsequently distribution among provinces. These recommendations are commonly called the NFC award. The NFC award deals with proceeds from only those taxes which are levied by the federal government and which constitute the divisible pool. These include all the important taxes, such as income tax, corporate tax, sales tax, import and export duties, certain excise duties and such other taxes as may be specified by the president. The president is also empowered to modify the distribution of revenues "as may be necessary or expedient." In addition, the NFC makes recommendations to the president regarding making of the federal grant-in aid to the provinces, the exercise by the central and provincial governments of the borrowing power under the constitution plus any other financial matter referred to it by the president.

Article 160 of the constitution provides for constituting the NFC every five years. The last NFC award was announced in 1997 when the share of the federal government and the provincial governments in the divisible pool was fixed at 62.5 percent and 37.5 percent respectively. A new NFC was constituted in 2002. However, as the Commission could not arrive at a consensus, the president in his discretion announced an award in 2006. It was decided that beginning financial year 2006-07 (FY07), the share of the provincial governments in the divisible pool would rise annually to 41.5 percent, 42.5 percent, 43.75 percent, 45.0 percent and 46.25 percent thereafter.

The major issue is the criteria on the basis of which tax revenue is to be distributed among the provinces. Presently, there is only one criterion -- population. Accordingly, the Punjab being the most populous province gets the lion's share of 57.36 percent, while Balochistan being the least populous province is entitled to the lowest share of 5.11 percent. The share of Sindh is 23.71 percent and that of the NWFP is 13.82 percent. There has long been a demand from the smaller provinces that the resource distribution criterion needs to be revised as it does not take into account their socio-economic needs. The position of Balochistan has been that distribution of resources should be based on development needs, backwardness and geographical size.

NWFP, being the poorest of all the provinces, has been calling for due consideration to poverty level and socio-economic needs in revenue distribution. Of late the province, the spectacle of religious militancy, has demanded that repercussions of the war against terrorism should also be taken into account as its meager resources are increasingly being spent on security related operations in disregard of developmental expenditure. Sindh has argued for broad-based criteria including revenue generation, population and backwardness. For the Punjab, and understandably so, population should continue to be the sole basis of the distribution of the national pie.

There is little doubt that making population the sole basis of revenue distribution is unfair as it gives undue advantage to the largest province at the expense of smaller ones. On the other hand, resource distribution on the basis of any other single criterion will also be unfair. If, for example, revenue generation is made the sole criterion, Sindh, which accounts for 65 percent of the national revenue, will become the major beneficiary, while geographical size alone will make Balochistan the major recipient of national revenue.

Thus the country needs multiple criteria for the NFC award which take into account the requirements of all the four provinces. In India, for example, Finance Commission award is based on broad-based criterion including population, area, income level, infrastructure development level, tax collection and fiscal discipline. In case of Pakistan, while population should not be the only basis, it should definitely be part of the criteria as a province with population greater than the combined population of the other three provinces does at least in one respect has greater financial needs. Similarly, backwardness, underdevelopment and poverty level have a legitimate claim to be considered while distributing revenue among provinces. Backwardness and poverty thrive on themselves. If a region is mired in poverty and underdevelopment, it will have a very low level and slow pace of economic activity thus impeding resource generation to fight these menaces.

In addition to being economic problems, backwardness and poverty have serious socio-political fallouts. Sense of economic deprivation creates social unrest and leads to political tensions and alienation. Underdevelopment is often the root cause of violence and, as in our case, of religious extremism. Development, on the other hand, is a most effective antidote to extremism.

Moreover, mere equity, though very important, should not be the only consideration for resource distribution. Efficiency has also a powerful claim. Scarce as resources are, they have to be used optimally. Therefore, improved fiscal performance should also be a factor in resource distribution. This makes revenue generation capacity and fiscal discipline another two elements of the multiple criteria for resource distribution.

However, there are some potential problems in devising multiple criteria. For instance, what weight should be given to various components of the criteria? Should population have a greater weight than underdevelopment? Should revenue generation capacity have greater weight than the poverty level? These problems spring from the fact that revision of the NFC award criteria will increase the relative share of some provinces at the expense of others. In other words, we will have a situation in which one province cannot be made better off (in the sense of having increased share of the national pie) while making the other worse off. For instance, if the relative share of Balochistan and NWFP in the NFC award is to go up, that of the other two provinces or at least the Punjab must go down. Policy makers need to decide to what extent they are willing to make a province better off at the expense of another. The decision will be influenced by both political and economic considerations.

Email: hussainhzaidi@gmail.com

The second-ever presidential vote in the Afghanistan's chaotic history of coups and wars is scheduled for August 20. International media and policy makers plus the Obama administration in Washington are linking the stability in Afghanistan with the stability in the region, therefore new strategies have been chalked out regarding Afghanistan by all the International, regional and local players. Washington has already increased its military presence to 56,000 troops from about 32,000 in late 2008, in part to provide extra security for the August vote. The US has also promised a further increase and the number will go up to 68,000 by year's end in order to hold the polls in a peaceful environment. On the other hand, the Taliban has call of a boycott of the poll and threatened to increase its attack to disrupt the polls.

According to Afghanistan's electoral system, the President is elected by direct votes to serve a five-year term and every presidential candidate is supposed to nominate his/her two vice-presidents while seeking nomination for himself/herself. The ultimate list released by Afghanistan's election commission on its official website revealed that 41 candidates including two women, one former president and two former cabinet ministers, are participating in this presidential vote. Three candidates out of 44 were barred from the polls by the Election Commission for failing to meet the requirement for the candidacy.

Political experts agree that there are only three strong contesters in the final list, Hamid Karzai, the incumbent President, Dr Asharaf Ghani Ahmedzai, the former Finance Minister and Abdullah Abdullah, the former Foreign Minister.

Hamid Karzai, hailing from the tribe of Popalzai of Kandahar, is again contesting the presidential poll despite severe criticism of corruption, bad governance, failure for eliminate the Taliban and the worst law and order situation in his tenure. In the beginning, the newly-elected Obama administration tried to find an alternative of Karzai and invited his four strongest rivals, including Dr Ashraf Ghani, Abdullah Abdullah, Gul Agha Sherazi, popular governor of Nangarhar and Anwar-ul-Ahday, former Finance Minister, to Washington for attending President Obama's oath-taking ceremony, but the US think tanks related to Afghanistan advised Obama to keep Karzai in the presidency for another term to strengthen the stabilisation process in Afghanistan.

Karzai registered the incumbent Vice President Karim Khalili and former Defense Minister Muhammad Qasim Fahim for positions as vice-presidents. Both candidates are notorious for their severe human rights abuses and corruption but the experts opine that due to the nominations of Khalili and Fahim, Karzai could easily get votes from the influential Tajik and Hazara communities in the polls. The supporters of Karzai claim that the main rationale behind the appointment of Fahim and Khalili is to strengthen the harmony amongst the different communities living in Afghanistan. To favour Karzai, ex-Nangarhar province Governor Gul Agha Sherazi had withdrawn his candidature which also strengthens Karzai's position in the presidential poll.

Dr Ashraf Ghani Ahmedzai, hailing from the province of Lugar, remained the Finance Minister after the fall of Taliban from 2002 to 2004. A PhD in Anthropology from Columbia University and the Head of Institute of State Effectiveness, Ghani is termed by Afghan political observers as Karzai's toughest rival in the elections especially in Pashtoon dominated areas of the country.

Ghani also served as the Chancellor of Kabul University, worked for the preparation of the Loya Jirga (Grand Assembly) and the constitution of Afghanistan. Ghani is reportedly considered close to Richard Holbrooke, recently appointed as Obama's special envoy for Afghanistan and Pakistan. Ghani nominated Muhammad Ayub Rafiqui and Dr Muhammad Ali Najeebzada as his vice-presidents; both are new faces in the politics of Afghanistan. In his election manifesto, Ghani highlighted the importance of establishing a representative administration, good governance, building a dynamic economy and creating employment opportunities for the Afghan people. According to Wali Agha, a local journalist from Kabul, Ghani is widely supported by Afghanistan's educated class and in Pashtoon tribal areas. Ghani may give a tough time to Karzai in the polls, but having less support in Tajik and Hazara areas, the possibility of his success is very low.  

Abdullah Abdullah, a close associate of late commander Ahmed Shah Masood, remained the Foreign Minister in both the transitional government and then Karzai's cabinet, but in 2006 he was dropped from the Cabinet. In the forthcoming presidential election, he is going to confront Karzai with keeping Chiragh Ali Chiragh (a Kabul University Professor) and Homayun Shah Asifi ( a political leader who is member of the royal family), as his vice president running mates. Experts believe that Abdullah's support appears largely limited to Tajik areas but the nominations of Fahim and Khalili by Karzai as vice-presidents can split Abdullah's Tajik vote badly.  

Former Taliban commander Mullah Salam Rocketi, hailing from the province of Zabul, earned his nicknamed for his skill at using rocket-propelled grenade launchers against Soviet troops in the 1980s, is also another contester for the presidency. After 9/11, Rocketi, commander for Jalalabad, surrendered his weapons to a spiritual figure Ismail Gilani, who was a supporter of Hamid Karzai, and chose to become politician and then became an MP from Zabul.

Shahnawaz Tanai, belonging from Khost, is a former communist leader of Khalaq faction of People's Democratic Party of Afghanistan (PDPA) and served as minister of defense from 1988 to 1990 under Dr. Najibullah and then with Gulbadin Hekmatyar's support, revolted against Dr. Najibullah's government in 1990, is also a candidate and is currently heading a political party known as Da Afghanistan Da Solay Ghorzang Gond (Afghanistan Peace movement).

The two women contenders are Dr Faroozan Fana and Shela Atta. The former is the widow of Abdul Rehman, an interim minister for Aviation and Tourism who was killed at Kabul Airport in a plane bound to New Delhi and the latter is a member of parliament who is famous for criticising Karzai in parliament.

Dr Abdul Jabbar Sabit, a former Attorney General fired in July last year accused for the corruption and breaches of law, is also willing to give a tough time to Karzai in the election. Sabit, a close aide of Gulbadin Hekmatyar in the past, is considered a controversial figure known for his anti-corruption drive across the country.

Hidayat Amin Arsala is also another contester. After receiving his doctorate in Economics from George Washington University, he joined World Bank. In 1987, he came back to Afghanistan to join the ongoing resistance movement against Soviet invasion and then served as member of the Supreme Council of Afghan unity of Mujahidin. After 9/11, he was also chosen vice-president of the Cabinet with Hamid Karzai in the transitional government.

A former Minister for Planning and serving MP, Dr Ramazan Bashardost is also a contender. Bashardost nominated Muhammad Musa Barekzai, a professor of Agriculture and Afifa Maroof, a famous human rights activist as vice-presidents.

Basir Ahmed Hotak, a journalist says the voting generally follows ethnic lines and appears certain to produce a president from the majority of Pashtoons. "Karzai is facing a huge criticism by his rivals in the poll especially regarding the corruption, law and order situation, bad governance and massacre of the common people but his election campaign in Afghanistan appears almost unassailable amid opposition disarray."

Hotak also reveals that many of the aspirants contesting the presidential vote have American passports who announced to cancel their US citizenships after a ban imposed by the courts but interestingly no one has submitted documentary proof to the courts as to the cancellation.

The Federal Ministry of Health has recently developed quality standards for accrediting hospitals to improve the value of healthcare -- an initiative that deserves due commendations. The significance of the plan is evident from the fact that throughout the world 30-40 percent patients do not get treatment of proven effectiveness; 20–25 percent patients get care that is not needed or is potentially harmful. Even in countries like the United States, preventable adverse events are a leading cause of death. The results of two studies show that as many as 98,000 Americans die in hospitals each year as a result of medical errors. Deaths due to preventable adverse events exceed the deaths attributable to motor vehicle accidents (43,458), breast cancer (42,297) or AIDS (16,516). This should be an eye opener for developing countries like Pakistan. 

Quality means more than just having the right facilities and equipment; it also means having the processes in place to maintain these. Quality means that patients are provided with friendly services where and when they need it and it means that providers in both public and private services are trained, competent and held responsible for the services they provide. Hence, quality is not just about inspection and control.

Although healthcare providers in Pakistan are competent and of international repute, systems cannot be dependent on the good intentions of individuals alone; checks and balances are crucial. While judgment is important in medicine, many things can be helped via clinical decision support systems to enhance quality and reduce errors and costs. Airline pilots go through written checklists every day for things they have done thousands of times but in medicine, use of such checklists is very rare. Here one may recall Murphy's Law "If anything can go wrong, it will". Dr Thomas Schwark, an international quality expert quite aptly adds "Murphy was an optimist." The need for standards and checklists is imperative.

A quality standard is a statement of expectation that defines the structures and processes that must be in place in an organisation to enhance the quality of care. Standards can serve as useful guides; not having followed them can result in serious outcomes. For example, a recent study showed that in Pakistan, tuberculosis (TB) is treated in 60 different ways and hence there is an ever increasing rate of drug resistant TB. Unfortunate incidents also occur due to confusion between "Look alike-Sound alike" (LASA) medication for example carelessness in prescriptions involving Erythromycin and Azithromycin, has dire consequences for the patients. Other examples of absence of standards include X-Ray machines not being contained in proper lead protected rooms and staff ignoring the monitoring of the amount of radiation they are exposed to with resultant harm. Medical waste is often not disposed of in a functional pit, needles and other medical waste are scattered in the vicinity of the healthcare facility. This leads to obvious hazardous outcomes for the staff, patients and the community.

Improvement in quality leading to better outcome is also a way to achieve cost-containment. As an example, a hospital in Lahore used a checklist for a drug called granulocyte colony-stimulating factor (G-CSF) that is used for a type of blood cancer. Its careless and indiscrete use was leading to wastage. The hospital enforced an agreed usage guideline with the result that the usage dropped to a fraction of what it was in the past with cost reduction from Rs60 million per year to Rs one million per year.

Paradoxically, many healthcare experts believe that quality improvement is costlier. While healthcare is one of the areas where the maxim "quality is free" is most prominent. Better health is less expensive than poor health. It becomes all the more relevant when the full costs to society of poor health are taken into consideration (e.g. poor worker's productivity and the ability to maintain employment and live independently). Better quality lowers costs through prevention of diseases, healthier living practices forestall the need to treat illness; early detection prevents complications and hence reduces costs; and an accurate diagnosis makes a good outcome for obvious reasons. Faster and appropriate treatment improves outcomes while reducing costs; every dollar spent on prevention reduces treatment expenditures. Quality care spends more on appropriate services in order to save through early intervention, reducing mistakes, minimising complications, and forestalling diseases recurrence. 

The people of Pakistan have the right to know whether they are getting value for their tax money of almost Rs 200 billion spent on health every year or not. Are costs resulting in intended benefits? Are hospitals doing any harm? These questions could be answered only if measurable standards are implemented because "if you can't measure it, you can't improve it."

Improving quality has become all the more relevant in the emerging global scenario that health care, long one of the most local of all businesses; now becoming increasingly global. Health will be the driving factor of our next global economic surge. Health is not only of great importance to the wellbeing of the population, but it is definitely also a very important economic factor, and one with great potential. In future, the world would see a lot more medical tourism with medical staff and patients crossing borders increasingly -- bringing prospects for economic benefits & greater access to health care. Asian hospital chains particularly those of Thailand, India, and Singapore are likely to be the leading gainers. Would this surge in global medical tourism also catalyse Pakistan's sclerotic health care system to think afresh or would it get trampled beneath its marching feet.

Appreciating the initiative of the Federal ministry of health it is recommended that standard be implemented on voluntary basis: wherever there is motivation and commitment. The main motivation usually is personal pride and pride in one's organisation.

Tangible motivators like the following should also be introduced:

- Awarding a plaque/certificate echoing status

- Accredited hospitals' names displayed on MoH Website

- Health Insurance companies to contract with accredited hospitals' on priority basis (gradually to be made mandatory)

- Government to use accredited private hospitals' services when required.

- Opportunities for medical tourism and resource generation.

- Potential for public hospitals to attract private patients with the hospitals allowed keeping and spending the money.

(The writer is a Health Economist and Population, Health and Development professional working as Senior Advisor for GTZ – Health Program in Pakistan.) Email: drjavaid04@gmail.com)