Pages

Friday, 8 November 2019

Performative Protests in Pakistan

By: Asiya Jawed

Participants holding ‘patriarchy’s funeralby covering a charpoy with white sheets and carrying it during Aurat March 2019. Photo Credit: Bismah Mughal

Pakistani women have managed to raise their voices in the country’s patriarchal landscape through decades of protest action around a range of issues, and have met with mixed success. With our ongoing history of internecine conflicts and civilian mobilizations for their rights, contentious performance as a protest strategy can prove to be a useful tool.
Contentious performance is a “learned and historically grounded way of making claims on other people” (Tilly 2008).  “People make claims with words such as condemn, oppose, resist, demand, beseech, support and reward. They also make claims with actions such as attacking, expelling, defacing, cursing, cheering, throwing flowers, singing songs, and carrying heroes on their shoulders” (Tilly 2008).These performances become a catalyst for conversation which helps to unify communities and demand justice from the authorities.
Rai (2015) defines political performance as a way to communicate meaning-making related to state institutions, policies, and discourses. Political performances have spurred several conversations in the local as well as global arena which has helped reduce the effects of state censorship against these protest actions.
At the Collective for Social Science Research, we are currently studying women’s leadership and contentious politics, which is the use of unruly and disruptive techniques to demand a change in government policy or to evolve people’s perspectives.  This research is part of the “Action for Empowerment and Accountability” (A4EA) project, a multi-country research programme in collaboration with the Institute of Development Studies (IDS),  focusing on how social and political action impact empowerment and accountability in fragile, conflict and violence-affected settings.
After analyzing several episodes of contentious politics and interviewing women involved in the protests, we found that women used performance as a protest strategy in different scenarios through various means. From holding patriarchy’s “janaza” (funeral procession) at the Aurat March to Hazara women not burying their loved ones, the spectrum of protest as performance has been wide and diverse. Art, values, culture, and symbolism have been a part of the range of contentious performances in a society where different forms of expression are increasingly restrained as civic space shrinks.
On 8th March 2019, several activist groups unified to chant slogans, and march together as a way to demand the rights of women and minorities residing in Pakistan. The Aurat March not only took place in metropolitan cities of Pakistan like Karachi, Lahore, and Islamabad but also in smaller urban centres such as Hyderabad and Multan. Weeks before the march, these cities were covered with posters, and invitations were sent via social media portals. Non-government organizations like the Fisherfolk Forum, the Lady Health Workers Association, as well as groups representing the Hindu and the Christian communities were mobilized to attend the event.
Sheema Kirmani, a leading women’s rights activist, classical dancer and founder of the theatre group Tehreek-e-Niswan sang and danced under the open skies at Karachi’s Frere Hall along with at least three thousand women, non-binary individuals and people from the trans community, and some men. The slogans and chants at the March varied from highlighting domestic issues to ending militarization. Participants held ‘patriarchy’s funeralby covering a charpoy with white sheets and carrying it on their shoulders. In a country where women don’t feel free in civic spaces, becoming pallbearers to patriarchy’s funeral was used as a form of symbolic resistance. This visual repertoire challenging norms and gender discriminatory rules is a prime example of how performance is used as a way to protest.
Using performance as a part of protest action is not a recent strategy. Over a 100,000 Lady Health Workers (LHW) - women hired by the government of Pakistan to provide family planning and reproductive health services in communities across the country - had their salaries compromised for several years. Even though they began protesting in 2008 to force the government to ensure timely payment, the fractured system couldn’t meet their demands. In April 2012, after several small protests, some of the LHWs threatened to commit suicide by setting themselves on fire at a sit-in in Islamabad. The performative nature of this protest drew the attention of authorities to their demands and they began to be met.
In February 2013, ethnic Hazara women used performativity to demand justice for the lives that were lost due to sectarian violence. They refused to bury their loved ones because they were furious with the authorities that failed to capture members of the Sunni militant group, Lashkar-e-Jhangvi, who bombed a market, killing 89 people belonging to the minority community. Hazara women carried out a sit-in with the deceased for four days and received widespread media attention.
Moreover, the Pashtun Tahafuz Movement (PTM), which aims to end discrimination against Pashtuns, gained momentum when Naqeebullah Mehsud, an aspiring model from the Pashtun community was killed in a fake encounter in Karachi by then police senior superintendent Rao Anwar. In solidarity with the movement, Pashtuns began wearing the famous red and black cap which was dubbed the ‘Pashteen’ cap after the leader of the movement, Manzoor Pashteen. However, selling the cap is now banned and shopkeepers are being punished if they help promote this symbol of PTM. Anwar was arrested but subsequently released on bail.
Recently, at Karachi Biennale 2019, artist Adeela Suleman put up an installation of 444 concrete pillars, one for each life allegedly taken by Rao Anwar extrajudicially. Her installation, “The Killing Fields of Karachi” was sealed off and banned from public viewing two hours after it went on display. Men belonging to security forces blocked the video featuring Mehsud’s father that was part of the installation. Unknown men vandalized the installation the next day stating that they were simply following orders given from above.  Moreover, the Biennale organizers justified the ban of her installation claiming that it did not honor this year’s thematic requirements. This episode spurred conversation, making civil society members eager to know more about Rao Anwar and PTM, indicating that the use of art is a robust form of protest action in the context of Pakistan’s politics.
Our research shows that women from different socio-economic backgrounds, religions, and ethnicities have come together to stage protest actions to grant them justice. Chanting, threatening to self-immolate and using visual aesthetics are ways in which Pakistani women have carried out creative resistance. Within a climate of shrinking civic space and censorship, women are coming up with increasingly innovative strategies to make their voices heard. 

Friday, 25 October 2019

Not so Easy Business

By: Muhammad Ali Jan

Pakistan is part of the top 10 economies that improved the most in 2018/19. Source: World Bank's Doing Business 2020 report


Pakistan has jumped 28 places in the World Bank’s (WB) global ‘Ease of Business’ rankings to become one of the world’s top 10 performers for 2019. Naturally, the government is ecstatic and the Prime Minister has tweeted a message congratulating everyone involved in achieving this feat. At a time when the Pakistan Tehreek-e-Insaf (PTI) is finding precious little to celebrate – either on the economic or political front – their jubilation is completely understandable. It is also true that for a government increasingly obsessed with its international image, as well as one extremely popular with overseas Pakistanis, these rankings are meaningful, just like they are meaningful for a section of global investors. However, it is also important to read these rankings with a great degree of caution, and key stakeholders as well as the public at large should be aware of their limitations as well as the errors of commission and omission inherent within them. Indeed, presenting these – or any other global cross-country ranking – as some kind of objective indicator for improved economic governance is not only wrong, it is also dangerously misleading.

Without getting into a detailed critique, I will simply highlight three main reasons why Pakistan’s 28 place jump – from 136 to 108 – may mean very little for actual business development and growth in the country. To begin with, what does the WB’s ‘Ease of Business’ report measure? Briefly put, what it attempts to asses and compare are administrative hurdles across a few areas of business regulation, such as registering property, getting electricity, paying taxes, getting taxes etc. In total, there are 11 main dimensions that are combined to make up this ranking. To be more precise, it tries to assess and compare the legally required time and costs of regulatory compliance for these aspects of private enterprise across the globe. It gathers information on these variables through four sources: the laws and regulations in the books, 'experts' (mostly lawyers, consultants and accountants) supposedly well acquainted with local business practices, certain government officials and the WB staff itself.

The first problem is that, by the Bank’s own admission, this is far from a comprehensive measure of the business environment since it does not cover, for example, aspects like security, macroeconomic stability, corruption, labour skills of the population, the underlying strength of institutions, the infrastructure or the financial system,- all of which impact how easy it is to set up a business. Given the lack of any coherent plan from the government for increasing investment that involves sub-regional businesses as well as the general environment of crushing stagflation, it is doubtful that these reforms on their own can lead to a spurt of new business development.

In addition, underlying these rankings is a certain laissez faire ideological bias so that simply a permissive environment is deemed enough to spur growth and for the fruits of this growth to be widespread. To give one example, while the government has made the payment of tax much simpler by introducing online payment modules, the timing, manner and rate of taxes themselves are considered by observers to be a reason why cash has disappeared from the market and the economy has slowed down. Yet, the ease of business ranking would register the reform on paper as a positive while its effects will not be counted.

This brings us to a much more fundamental problem with the ranking: that its source of information involves tax lawyers, accountants, government officials but not entrepreneurs themselves. This is because the report is mainly about how rules and regulations exist on paper and not how they are experienced by actual actors (i.e. firms) on the ground. A much more reliable measure of actual experience are the WB’s 'Enterprise Surveys' which cover aspects such as access to finance, corruption, infrastructure, crime, and competition by interviewing a large random sample of managers and business owners themselves across a range of enterprise types in different parts of the country. What these reports show is that for economies like Pakistan, where close to 70% of all livelihoods are earned in the Informal economy, the disjuncture between laws on paper and actual experience can be monstrous. In fact, scholars who have compared the two surveys have found almost ‘zero correlation’ between improvement in the ranking in terms of laws and actual experience on the ground.

A final limitation of the report is that, even if one were to accept that the formal laws and regulations are important, they cover them for only two main cities, namely Karachi (where the Sindh government was as involved in these reforms as the federal government) and Lahore. Therefore, in addition to the limitation of only looking at laws on paper and not actual experience on the ground, ignoring the vast informal economy, restricting surveys to legal and government experts and covering a few aspects of regulation with a somewhat simplistic idea that less regulation is necessarily better, the report also suffers from a lack of coverage, which for a country as large and varied as Pakistan, is extremely misleading.

This is not to say that the report is entirely devoid of substance or that any other government would not have flaunted a report like this. It is also true that the global 'development industry' continues churn out such reports, even when the rankings contradict one another; to give an example, even as Pakistan has jumped many points on this index, it has dropped three positions from 107 to 110 on the global competitiveness rankings. In fact, the one key lesson of the current economic morass in the country is this: policy makers must dispense with the ‘one-size fits all’ approach to development, particularly that borrowed heavily from the Bank’s neoliberal ‘good governance’ agenda with its laundry list of reforms.

Instead, countries must rely on their own resources (of course, not in an autarkic sense) to chart a home-grown plan for reform, economic growth, decent employment and poverty reduction. Of course, that would require reaching across the aisle - both economically and politically - to people one may not always agree with or like but who are critical stakeholders if any stable and prosperous political economy arrangement is ever to evolve.

The writer is a Research Associate with the School of Global and Area Studies, University of Oxford. He can be reached at muhammad.jan@area.ox.ac.uk.


Wednesday, 25 September 2019

Climate Action in Pakistan: Policies at the Top versus Voices at the Bottom

By: Ayesha Mysorewala

Pakistani's taking shelter on higher ground near Thatta after the August 2010 flood. Source: Encyclopedia Britannica

The history of the climate change movement is rooted in obscure technical concerns that are disconnected from the understanding of lay people. Roughly over the past couple of decades, however, the concern has increasingly captured widespread public consciousness and international regulatory interests as the seriousness of the problem has gradually been realized. This is evident in international diplomatic consensus, such as the United Nations Framework Convention on Climate Change (UNFCCC) and the Paris Agreement, on limiting carbon emissions. The rapid political response is undoubtedly a testimony to the authority of technical information translating into political action.[1]

The climate change debate, however, as Naomi Klein argues in a recent article, has for far too long been compartmentalized and siloed from other crises we face. This is perhaps one reason why there is continued inaction in many countries. Within this context, this blog highlights the perils associated with technocratic approaches to DRM and climate change diverging from the experiences of riverine communities in Pakistan.

How is climate change understood in Pakistan?
In recent fieldwork in Thatta for a study on social exclusion in disaster risk management (DRM) processes, people from more vulnerable communities, such as the residents of Katcho (riverine areas unprotected by embankments), told us that disasters are part and parcel of other contingencies that they face in everyday life.

This is not to say that people are unaware of climate change. However, instead of technoscientific accounts of climate change, people framed their issues in the context of environmental issues (such as weather patterns and intensities of disasters). They made sense of it through their memories of specific experiences that are a function of existing vulnerabilities due to their geographical location, class, caste/kinship group, land ownership and gender. Each of these dimensions is rooted in historical processes of marginalization that intersect with each other, and the impacts of climate change.

Similarly, paying heed to early warnings issued by the government, based on predictions of rain millimetres and water flows (that originate from the MET department and trickle down to local government/district level authorities), gave way to peoples own sensory experiences related to the physical landscape. Reactions to these warnings were again related to various socioeconomic factors. For example, those who were better off were able to react well in advance, save their belongings and acquire help from relatives to move to safe places. More vulnerable groups and individuals had to wait till the very last minute for rescue due to lack of resources to access vehicles, inability to find a safe space for or evacuation, women’s needs for privacy and seclusion, or immobility due to disability.

Top-down policies
A lack of understanding of these realities result in top-down policies based on a widespread institutional narrative that local communities are ignorant and lack awareness. The recently passed Climate Change Act for example, although an important step towards fulfilling global commitments, has been criticized for (1) being top-down and disconnected from local realities and political context of Pakistan, and (2) lacking direction on how these commitments will be achieved.
We need to develop political spaces that give opportunity for states and citizens to interact with each other and for policy to be context driven. This has implications for greater trust and two-way communication between high level bodies at the top and those who are at the frontlines of the impacts of climate change.   

There are recent examples of improved state-citizen relations due to climate action and DRM policies that pay attention to local issues in tandem with technical approaches. In her research on the post-flood response in 2010, Ayesha Siddiqi notes that the use of digitized citizenship by NADRA to universally address the needs of people opened a new space for state-citizen relations that was based on entitlements and rights, rather than systems of patronage. This developed a new narrative that diverged from the dominant one of the state being absent.

Recently, over a thousand farmers in Sindh marched to demand a water emergency. A few thousand more young people rallied for climate action last Friday across the country. This shows that there is not just an appetite for change but also a willingness to engage with the state for action. Prime Minister Imran Khan also delivered a speech at the United Nations Climate Action Summit this week, requesting international coordination and assistance. While he waits, perhaps the Prime Minister can start with a coordinated response by the Pakistani state and an examination of the citizens’ demands.






[1] Demeritt argues that scientific concerns only partially drove this response. The public outrage following damages due to large disasters are part responsible for these actions.

Saturday, 31 August 2019

Women Leaders in Action: Lady Health Workers’ Protests

By Komal Qidwai

A health worker vaccinates a child during a polio vaccination campaign in a rural area in Punjab.
Photo credit: flickr.com
Since 2002, Lady Health Workers (LHWs) have protested against low stipends and delayed payments. The LHW Program, initiated by Benazir Bhutto in 1994, now employs over 100,000 workers. The aim of the program is to provide primary health services to women in rural and urban slum areas through LHWs, who are residents of the community they work for. Until 2012, LHWs were contractual employees. After their regularization in early 2013, they became full-fledged government employees, entitled to benefits, guaranteed payment of salaries, and a clear trajectory for career advancement through a service structure.

LHWs employ a range of protest strategies to have their demands heard. From sit-ins and marches to hunger strikes and self-immolation, these women-led protests have managed to achieve regularization, as well as increases in salaries. LHW’s protest action is one example of women’s involvement in contentious politics in Pakistan, which is currently being researched at the Collective for Social Science Research. We are conducting this study under the A4EA (Action for Empowerment and Accountability) research program, in collaboration with the Institute of Development Studies (IDS), University of Sussex.

According to Ivan Gomza, contentious politics refers to political action which operates outside of institutions, such as government bodies. Disadvantaged groups use protests to voice their demands through collective action. Our research is focused on understanding women’s role in this type of political action, including the emergence of women leaders, their demands, and protest strategies.

Along with my colleagues, I interviewed founder and president of the All Pakistan Lady Health Workers’ Welfare Association, Bushra Arain. We learned that initially she struggled for permission to join the program as she faced resistance from her in-laws, extended family and husband. Through our interviews with women leaders in other types of protest action, we found that support from male family members is important for the emergence of women leaders. The same is true for Arain, who had to convince her family to become an LHW.

After joining the program, Arain was quickly promoted to the position of a Lady Health Supervisor. She experienced harassment from male colleagues, such as a doctor who was responsible for training her. She and other supervisors protested/objected and had him removed from the program. At the same time, Arain also realized that the program was helping a large number of people, but its workers were not being paid enough or on time. By 2008, she had formed the LHW Association and in 2010, LHWs across all four provinces protested on the streets, demanding increase in wages and regularization. To mobilize LHWs for collective action, she travelled all over Pakistan, forging connections with workers in different provinces. Her leadership style matches that of many other women leaders from our other interviews – she engages in grass-roots mobilization herself, taking on responsibility and bearing high personal costs such as threats to safety and distance from her children and family.

Many of the LHW street protests are carefully staged. Describing a hunger strike in 2010 outside the Islamabad Press Club, Arain says that there were forty protesters in the sit-in, and every time one would leave, she would be replaced by another. This way, the protestors were able to maintain their numbers. In another sit-in during April, 2012, some of the protestors gave the government an ultimatum - either their demands for regularization be heard by 3 p.m., or they would self-immolate. A lack of government responsiveness pushed twenty-five protestors to sprinkle petrol on themselves, and one driver even sustained burn injuries. This compelled government officials to step in and assure the protestors that their demands would be met.

Staging protests is one of the many organizational strategies LHWs employ. They have also effectively used the courts by filing a petition in the Supreme Court in 2010 for their regularization and increase in salaries. However, it was the cruel treatment of the protestors at the hands of the police in 2011 which finally prompted then Chief Justice of the Supreme Court, Iftikhar Muhammad Chaudhry to take suo moto notice of LHWs’ demands. Even after the Supreme Court issued orders for their regularization, there were delays in implementation and LHWs continued protesting to ensure the court orders were followed through. Arain describes this combination of using courts and street protests, “The world saw that (their protest) and pressurized the government.” So creating a spectacle by staging protests induces the government to sit down with the protestors, undertake formal negotiations about their demands, and follow through with necessary action.

However, they could not have filed a petition without legal aid, and Arain claims that advocates such as Qazi Anwar, now president of the Supreme Court Bar Association of Pakistan, helped LHWs draft and file the court petition. Forging alliances, then, is also a key strategy for successful protest action. As early as 2000, before the LHW Association was formed, it was through the help of the All Pakistan Women’s Association (APWA), Aurat Foundation, and the Pakistan Paramedical Association that Arain and her colleagues had the doctor who was allegedly sexually harassing them removed from the LHW program. LHWs also form alliances with influential politicians, such as Marvi Memon. Memon was an MNA from 2008 to 2011, and her presence at their protests during those years afforded the LHWs some protection from police brutality. Even now, LHWs continue to build alliances, such as the Aurat March, and are engaging in protests to improve their conditions.

Apart from having their demands met, engaging in protest action has also led to personal empowerment for many LHWs. Arain, for instance, recalls that at the beginning of her career, she used to cry if she was chided by a person of authority. Now, after threats and beatings, she is not afraid of any backlash. Other women in the Association look at her with reverence, and her charisma certainly plays a role in marking her out as a leader. She has built this credibility over a long period of struggle. Our interviews in relation to other types of protest action reveal that many women at the forefront of protest actions have followed similar trajectories – enduring high personal costs, forming alliances, learning new organizational strategies, and emerging as leaders.

Friday, 2 August 2019

HIV in Pakistan: Who knows, who cares?

By Shehrzadae Moeed and Adil Sayeed

Photo credit: Torange.biz


In April 2019, a doctor in Larkana’s Ratodero sub-district was arrested for allegedly passing on Human Immunodeficiency Virus, or HIV, to his patients. In the aftermath, as the Government of Sindh moved into firefighting mode, more than 30,000 individuals were screened, of which 851 tested HIV positive. More than 64% of these were under the age of six. In Kot Imrana, Punjab, the number of people with HIV increased from 1.4% in June 2018 to 13.4% in January 2019. It has been reported that over 5000 quack doctors operate in the area and 869 people have been diagnosed with AIDS. A recent report by the UNAIDS puts Pakistan on a list of 11 countries with the highest global prevalence of HIV, at 13%.

Why has Pakistan experienced sharply increased rates of HIV? In this blog, we will look at the data to assess why HIV remains prevalent and use cross-country evidence to learn lessons on tackling what is a very manageable illness.

HIV and its causes
HIV is an infectious disease that is spread through the blood, such as through used syringes, or transmitted sexually. It can also be transmitted to children if the mother is pregnant. The infection damages the immune system, and its most advanced stage develops into AIDS (Acquired Immune Deficiency Syndrome), which is life-threatening. It is a serious illness with global efforts to tackle it. However, even though it is a lifelong condition, developments in medicine mean that, with proper and regular treatment, an infected person can live a full life.

Commonly, the causes of the growth of HIV prevalence in Pakistan, similar to many developing countries, are attributed to medical negligence, a broken healthcare system, unregistered blood banks, and unlicensed practitioners, including quacks. In addition to this, the common Pakistani “penchant for receiving injections and drips as quick fix in lieu of healthy nutritional lifestyles” contributes to the inclining HIV prevalence in Pakistan.

Further, migrant labour forces open to commercial sex, and increasing man-to-man sexual activity, also contribute to this. In any other country where same-gender sex isn’t a criminal offence, governments work hard to ensure the practice of safe sex. In Pakistan, however, taboos around sexual health make it difficult for sufferers to seek help or even find a support group. If no one can talk about sex, who’s ever going to talk about safe-sex?

What does the data tell us
While the proximate causes commonly discussed in the media may have to do with unsafe sex, reusing needles, blood transfusions, and similar unsafe practices arising from quackery, medical negligence or drug use, the data suggests that the underlying cause, however, is the lack of awareness of sexually transmitted illnesses (STIs).

In the Pakistan Demographic and Health Survey (PDHS) 2017-18, only 32% of women and 67% of men reported that they had heard of AIDS. In Sindh, this is even lower, with 26% of women and 49% of men reported being aware of AIDS. These figures are very low.

Furthermore, out of every 100 women, less than 4 are aware of the fact that there is a treatment for HIV and less than 3 know where to receive HIV treatment. Similarly, less than 33% of men are aware of the fact that there is a treatment for HIV, and less than a quarter have any knowledge of treatment centers. Comprehensive knowledge about HIV is abysmally low, with only 4% women and 10% men being familiar with the details of this illness.

A lack of awareness of this public health challenge is thus endemic – a flip side of the same coin, however, is the discrimination among those who are aware. In the same survey, more than 50% of the respondents said they would not buy fresh vegetables from a shopkeeper who has HIV. Similarly, 46% of women and 48% of men who are aware of AIDS said they would not want HIV positive children to go to a school with those unaffected by this illness.

Discrimination in a population acts as a disincentive for people to get tested and treated. It is the taboo associated with HIV and AIDS that also leads to less people being open about it, thereby reinforcing the lack of awareness.

Way forward
What is clear is that the Government of Pakistan’s National AIDS Control Programme (NACP), which was established in 1986-87 and has received significant donor financing, has been ineffective in tackling the social causes of HIV/AIDS prevalence. Perhaps there is a need to learn from other countries – after all, Pakistan is not the first country facing this issue.

In Brazil, for example, massive reduction in cases can be largely attributed to a massive awareness program (prevention) coupled with widespread distribution of free medication (treatment). Their ministry of health also utilized social media in a 2014 awareness campaign. This also assisted in reducing the population growth rate which currently stands at a relatively low 0.8% as compared to Pakistan’s 2% annual growth rate. The success of Brazil’s AIDS campaigns is evident today as 84% of the population with HIV is aware of their condition as compared to just 15% in Pakistan.

In sum, Pakistan needs to rethink its strategy to fight HIV and AIDS. HIV, if caught and treated, can yield a normal life for those infected with it. If not treated properly, however, HIV can quickly develop into AIDS, which is life-threatening and a miserable condition to be in for someone infected with it. The spreading of STI’s and the chances of HIV developing into its last stage of AIDS are particularly high because of the lack of awareness and stigma associated with them in Pakistan. The NACP needs to tackle these head on, perhaps by talking about these issues from an early age, including sexual education in school, as other countries, including Brazil, have done. As long as there is a lack of awareness regarding the issue, these epidemics will continue to prevail and the people will continue to suffer.


The authors were interns at the Collective in July 2019.

Saturday, 29 June 2019

Reproductive rights

by Ayesha Khan

Sindh High Court
Photo credit: Wikimedia Commons


We are one step closer to having maternal health recognised as an inalienable right in the Constitution. The Sindh High Court recently ordered the government to make good on its commitment to set up four fully functioning obstetric fistula repair centres in the province, in response to a petition pending since 2015.

Friday, 14 June 2019

Low Cost, Low Access? A Misplaced Focus on Drug Pricing in Pakistan

By Kabeer Dawani

Source: https://www.goodfreephotos.com

There has been uproar in the media on recent increases in medicine prices, some of which are viewed as exorbitant. Many opposition politicians have made public statements condemning the government for this and social media is rife with disapproval. Further, as part of the cabinet reshuffle on 18th April 2019, the Federal Health Minister was removed, with the media claiming that this is because of the increased medicine prices.

Given medicines are a necessity, and in an environment with high inflation, some of the uproar is understandable; but are the claims that there is overpricing correct, or were these price increases legitimate? And what does pricing mean for availability of essential medicines, which are vital for public health? For the past six months I have been engaged in a research project on strategies to address corruption in the pharmaceutical sector, in partnership with the SOAS Anti-Corruption Evidence research consortium. While the project is still ongoing, I will borrow from this work to provide historical context to this round of price increases, point out negative consequences of controlling prices, and make a case for decontrolling prices for non-essential medicines.

Medicine Pricing Over the Years
The pharmaceutical sector is unique in Pakistan in that the universe of products have controlled prices, which are by and large enforced. This control is inconsistent and prone to rent-seeking. There was a virtual freeze of prices from 2001 to 2013, despite rising costs of production. Then in October 2013 the Nawaz Sharif government initially increased, but very quickly revoked this increase. The manufacturers went to court and managed to get a stay on the original increase. Following that, a pricing policy was introduced for the first time in 2015.

Due to inconsistent applications of the policy and pricing disparities from the past, litigation on medicine prices in various courts piled up, including on the 2015 policy. Eventually, the Supreme Court took all the cases together through a suo motu notice. On the SC’s orders and with due consultation, another pricing policy was introduced in 2018.

Over the past few years, the costs of production – mainly for raw materials, 95% of which are imported – have increased drastically due to two factors. First, devaluation of the Rupee since 2017 has increased this cost. Second, China’s environmental policy has resulted in an increase of prices of chemicals, and since China is the biggest supplier for Pakistan, this means higher raw material costs.

It is in this context that medicine prices were increased recently. In December 2018, the Drug Regulatory Authority of Pakistan (DRAP), through three Statutory Regulatory Orders (SROs) , allowed an increase in 600-plus medicines because of ‘hardship cases’ (but also reduced prices for 395 medicines). Then, acting on a SC order, and in lieu of the currency devaluation, DRAP permitted another increase of 9% for essential medicines and 15% for non-essential medicines. While there is no doubt some manufacturers may have increased their prices beyond that permissible, in general the price increase was merited and, in fact, long overdue.

Costs of Over-Regulation
The conventional argument in favour of controlling prices of medicines is a populist one: governments put a ceiling on medicine prices so as to enable the low income population to have access to affordable medicine. This seems to be borne out by the current controversy over increased prices, and the recent announcement by the Pakistan Pharmaceutical Manufacturers Association (PPMA) to reduce prices by 10-15 percent of 464 medicines ‘voluntarily’. There is indeed public pressure to keep prices in check – but does this also have a cost to economic growth and public health?

Our research into this shows that there are significant negative consequences to the strict price controls practiced in Pakistan. These costs pertain to shortages of key medicines, often leading to black marketing and increased imports, higher drug resistance, and withdrawal of multinational firms.

Businesses, by definition, operate for profit, and pharmaceutical manufacturers are no different. With a freeze in prices and no consistent increases, even though initial prices may yield high margins for manufacturers, these margins are inevitably squeezed over time because of inflation. The result is that producing a medicine is not profitable any more, leading to shortages of many essential medicines. For example, in 2015 there were multiple reports of a shortage in medicines for tuberculosis. When there are shortages, some people hoard supplies and sell on the black market for up to 50 times the original price, or the same drug is imported for a higher cost. The consequence of either an absence of a key medicine or much higher monetary costs is thus borne by the consumer.

The shortage hurts the poorest segments of society, who can only afford to get medicines from public health facilities, the most. One study estimated that, of a basket of essential medicines, only 15% are available in the public sector. This is not only because of public procurement issues because in the private sector, availability, at 31%, was twice as better but still much below what it should be.

When a medicine is not profitable to produce anymore, many manufacturers register a new drug to produce. At registration, manufacturers can get a price with high margins so that even if there is no increase over the short-to-medium term, they can make a profit. Thus, many first-generation drugs have stopped being made and instead manufacturers have gone on to produce second and third-generation medicines, which are more expensive. These new drugs can have prices that are ten-times higher than the original first-generation medicine. Again, the burden of this falls on the consumer whose out-of-pocket expenditure rises.

In addition to the costs to the general population, there is also a negative consequence to the economy and to public health because many multinational companies (MNCs) have exited the Pakistani market. Since there is no research and development of drugs in Pakistan, all new products are brought into the health system through MNCs who develop new medicines elsewhere. MNCs also have higher standards than local firms and invest heavily in developing human capital through trainings. This has a positive spillover in the local industry as pharmacists who are trained in these firms then go on to improve the quality of medicines being produced locally. Thus, the exit of MNCs, in addition to the economic costs of disinvestment, also leads to negative consequences on public health through other means.

Policy Implications
There appears to be a surprisingly effective political consensus on keeping medicine prices suppressed, and to which citizens hold governments accountable. Even prices that were raised through the proper mechanism, as defined in the pricing policy, have been criticized. However, given the issues I have described above, this consensus is misplaced because it misses out on the more important goal of access to medicines. Focusing only on affordability has the negative, and hugely important, consequence of unavailability of key medicines and in turn affects public health.

There is an urgent need to decontrol prices for non-essential medicines. With more than 750 manufacturers, there is sufficient competition in the industry to ensure that no one increases prices astronomically. In fact, one manufacturer told me that before the devaluation hit them, they used to sell 70% of their medicines below the notified maximum retail price.

The state can, however, rationally control prices of essential drugs. This will ensure that medicines which are prioritized will not have prices spiraling out of control.

More importantly, I would argue there needs to be a shift in the current political consensus. Instead of keeping prices in check, access to affordable medicines should be made through the existing government (primary, secondary and tertiary) healthcare system. Provincial governments already do this at scale and this can be improved and expanded.

Finally, in the medium term there also needs to be a concerted effort by the state to incentivize the production of pharmaceutical raw materials within Pakistan. Not only will this help reduce the trade deficit, it will also reduce the exposure of prices to fluctuations in the currency market, create jobs, and spur economic growth.


Disclaimer: This blog is an output of a research programme (SOAS-ACE) funded by UK Aid from the UK government. The views presented in this blog are those of the author and do not necessarily represent the views of the UK Government’s official policies.

A version of this blog was originally published by Prism, Dawn.