Thursday, 12 November 2020

Healthcare Workers’ Mobilization in Pakistan

 By Asiya Jawed

"Halima Leghari, President, All Sindh Health Workers and Employees Union with other health workers at the October 2020 protest in Islamabad"

Health workers around the world today are glorified for saving other people’s lives while risking their own during the Covid-19 pandemic. Yet the basic human rights of these vulnerable heroes are being undermined, as Amnesty International warns of another crisis in which thousands of health workers are dying to save others. The shortage of lifesaving protective equipment, coupled with unfair pay and lack of benefits in numerous countries, has forced health workers to mobilize and protest against the conditions in which they have to work during the pandemic.

In Pakistan, too, the rights and lives of health workers have been deeply compromised during the pandemic response. Since different cadres of health service providers already have a history of mobilizing, could their response to current risks provide the catalyst for them to join forces to transform the conditions of work in the health sector? Our research suggests this may be happening amidst the pandemic as they collectively act to bring forward new demands and solidify older ones.

At the Collective for Social Science Research, we have been following changes in civic space since Covid-19 first emerged in the country in March. This is part of the ‘Action for Empowerment and Accountability’ (A4EA) research programme - a multi-country study in collaboration with the Institute of Development Studies (IDS) - focusing on how social and political action impacts empowerment and accountability in fragile, conflict and violence-affected settings. We conduct detailed media tracking, monthly observatory panels, and interviews with civil society actors to discuss changes as they happen.

During March 2020, as healthcare workers in Pakistan began gearing themselves to fight the virus, the Punjab Assembly passed the controversial and contested Medical Teaching Institutions (MTI) Reforms Bill, ironically on the same day as the World Health Organization (WHO) recognized the spread of Covid-19 as a pandemic. The Act was formulated as a result of a deal with the International Monetary Fund (IMF) in May 2019, which stipulated cuts to social spending ultimately privatizing public health facilities. Health workers have been fighting against the draft Act for a year now; they created the Grand Health Alliance (GHA) to pressure the government to repeal the Act in Punjab. The protestors argued that the Act was harmful for both health workers and patients. It gives health workers the status of contractual employees as opposed to those within a civil service structure, thus affecting their job security. It is also ‘anti-patient’ because the privatization of healthcare will make it less accessible to the poor.

Even though GHA initiated its protests in Punjab, they now have chapters in all provinces. Pakistani doctors aren’t well-equipped to deal with Covid-19 patients - many doctors have lost their lives whilst saving Covid-19 patients due to high exposure to the virus. Doctors have protested for the provision of PPEs and against non-payment of salaries by boycotting OPDs and staging hunger strikes in urban centres. Dr. Alia Haider, a practitioner and activist based in Lahore, said when she went to hospitals to distribute PPEs, doctors demanded that the PPEs should be given directly to them instead of the superintendents. “If you are sending a soldier to the borderline, you equip them. You give them guns, bulletproof jackets etc. However, when doctors are going in the frontline to save patients, they aren't given any PPEs. So, this means that the government believes that a doctor's life is not as important as a soldier's.”

Our tracking of civic spaces during the time of Covid-19 has revealed that health workers have been arrested, baton-charged and shamed during protests for not being present in the frontline during the pandemic. For example, in Quetta, police
baton-charged and arrested several young doctors protesting for provision of PPEs and in Lahore, they thrashed  members of GHA protesting at a hunger strike. Dr. Haider claims health workers were demonized for demanding their basic rights, “There was always this notion that doctors and health workers are mostly working for their own means as they are closing down OPDs. But the real situation was totally opposite and we all got to see it. Balochistan's doctors protested, and they were arrested and put in jail for two days.”

Nurses hired during the emergency situation say they are being mistreated through inadequate provision of  PPEs and irregular salaries. During May, on International Nurses’ Day, they staged a sit-in outside the Karachi Press Club to draw attention to the reality that 40 nurses in Sindh were already infected with the virus. Months after the outbreak of Covid-19, nurses protested outside the Chief Minister’s house due to unmet demands but they were baton-charged and ten arrested. Still, they announced that they would not back down until their demands were met, and went ahead to join the LHWs in their October protests.

Moreover, amidst a massive public health crisis, the National Assembly passed a surprise bill mandating all medical students, many of whom began to volunteer after the spread of the virus, to give the National License Examination (NLE). Previously, only foreign graduates were obligated to give the NLE if they wanted to practice medicine in Pakistan. In another move, the Pakistan Medical and Dental Council (PMDC) was replaced with Pakistan Medical Council (PMC) to enforce the NLE. Prime Minister Imran Khan believes that mandating NLE will raise the standards of local medical and dental colleges to an international level, but medical experts deem it to be discriminatory and illogical. Students will only focus on clearing the NLE which will compromise their overall learning and adversely impact the quality of education.

Compounding the problem, PMC cannot regulate the fee charged by medical colleges which means that financial burden on students’ families will increase and several individuals won’t be able to afford the extortionate fee. The Young Doctors’ Association (YDA) staged several protests after this unnecessary bill was passed, and hashtags such as #werejectNLE and #werejectPMC began trending on social media. The Council, encompassing bureaucrats rather than medical experts, recently announced that it will conduct the Medical and Dental College Admission Test (MDCAT) without an academic board or medical authority mandated to design the syllabus and conduct this examination. Infuriated students filed a petition against MDCAT. After vigorous online activism, Sindh High Court delayed the examination for 15 days so the Council could develop a board and authority to meet students’ rightful demands.

Lady Health Workers are essential to Pakistan’s response under Covid-19, as the largest cadre of community-based healthcare providers in the country. LHWs have been mobilizing since 2010 against insecure working conditions, characterized by irregular and inadequate salaries, and part-time status as government employees. The pandemic has only worsened their situation.  

Halima Leghari, President, All Sindh Health Workers and Employees Union says LHWs haven’t been given any facilities or kits during Covid-19 and they are working on the frontline without any protection or security. They didn’t receive sanitizers or masks as protection from the highly contagious virus and purchased protective equipment themselves. She claims that LHWs in Sindh were receiving a health risk allowance since Covid-19 began spreading in Pakistan but that allowance halted in October, due to which health workers in Sindh began boycotting OPDs. Bushra Arain, President of Lady Health Workers’ Association also complained about the lack of requisite equipment and reported that it was difficult for LHWs continue their work as contraceptive supplies began running out and they were unable to fulfill their communities’ needs.

On October 14th, frustrated LHWs and pensioners staged a sit-in in front of the Parliament House demanding changes in the service structure, increase in pensions, life insurance, salary increases and protection in the anti-polio campaign. LHWs protested in dire conditions at D-Chowk in Islamabad for seven days and only ended their sit-in when government promised to meet their demands in the next few months.

With the healthcare system in Pakistan crippled already, it appears that health workers, essential but vulnerable, have no choice but to protest during these conditions of an unprecedented pandemic. Neglected demands coupled with unjust new regulations are forcing critical stakeholders from the health sector to stage collective protests to amplify their voices. Clearly, a pandemic is not the time to privatize the health sector, introduce NLEs or stop health risk allowances. Their demands should be a priority for government in its pandemic response, before the different cadres of health service providers unite in their refusal to work without adequate protections and conditions of employment.


Wednesday, 30 September 2020

Absent Again: Women and the Covid-19 Response in Pakistan

By: Syeda Haleema Hasan

Photo by Wasim Gazdar Photography

Last month, Pakistan’s Prime Minister Imran Khan assured that the country’s economy was on the path to recovery as the pandemic’s intensity lessened. The state has adopted measures to curb the virus and mitigate its disastrous effects, including imposing lockdowns and introducing economic relief packages. However, Pakistan’s Covid-19 response is largely missing one half of its population: women. The pandemic’s disruptive impact disproportionately affects women and any recovery failing to incorporate an intersectional, gendered approach is incomplete. This blog provides a summary of the gendered economic impact of the pandemic, critically analyzes Pakistan’s major covid-19 response strategies with respect to women and finally explores possibilities for remedial strategies. It is also important to remember gender as a spectrum, with women being one marginalized gender focused in this blog.

In order to understand COVID-19’s compounded effects on Pakistani women, it is important to know the country’s existing multidimensional gender inequalities that make women and girls particularly vulnerable to the pandemic and its effects. The table below provides some context, illustrating Pakistan’s performance on two global gender equality indicators. India and Bangladesh, countries with similar socio-economic characteristics and a shared history with Pakistan, fare much better in comparison on the same indicators.

*Higher ratio value demonstrates greater gender equality.

A policy brief issued by the UN Secretary General in April 2020 describes the impact of Covid-19 on women as far-reaching and long lasting as a result of existing gender inequalities. The Ebola Virus, another deadly disease with similar prevention measures such as quarantines, severely impacted women’s economic activity with the effects persisting for women even after men’s economic activity had returned to pre-crisis levels. Similar projections have emerged for Covid-19 which warn that labor market conditions for women are unlikely to be restored to original levels (which are already poor in Pakistan) even after preventive measures are lifted. The causes are manifold, including increased unpaid care work and household responsibilities of women, severely restricted female mobility and high levels of informal sector and vulnerable employment as opposed to men.

Figure 1: Female to male ratio of average time spent on unpaid domestic, care and volunteer work in a 24-hour period (source: OECD)

Figure 2: Statistics on female employment (source: Pakistan Labor Force Survey 2017-18; Pakistan Employment Trends 2018)

Figures 1 and 2 provide some statistics on these conditions. Time spent in unpaid domestic, care and volunteer work by Pakistani women is 10 times higher than men and more than women in both Bangladesh and India (figure 1). These numbers are likely to be greater with increased domestic responsibilities (health, elderly and child care) as a result of the pandemic. As the time spent on care work increases, women’s ability to participate in the workforce decreases. The World Economic Forum examined this correlation for a host of countries, finding that the greater the proportion of unpaid domestic work per day, the lower was female economic participation and opportunity. This suggests that the existing very low female labor force participation in Pakistan (20%) is likely to drop further unless targeted efforts are made to counter this. Care work also limits women’s ability to adjust to the changing circumstances, such as carrying out work remotely. Additionally, a greater employment of women in vulnerable jobs (figure 2) means weaker contracts and poorer work conditions. This means women are more susceptible to the layoffs and income declines consequent of COVID-19. 

The pandemic’s gendered effects have consequences extending beyond the women themselves. For instance, higher female absenteeism and drop-outs in schools and decreased female labor force participation have been known to adversely impact healthcare (for women and children both), economic growth and incidence of child marriage amongst other consequences. In countries like Pakistan, where harmful gender attitudes and norms already threaten the safety and survival of women, these effects are expected to be far worse.

The Pakistani state has undertaken some measures to combat the virus and its effects. Its response includes complete lockdowns, partial or smart lockdowns in virus ‘hotspots’, mobilizing the National Command and Operation Centre to coordinate efforts against COVID-19 and disbursement of a one-off payment of PKR 12,000 under the Ehsaas Emergency Cash fund. Additionally, the State Bank reduced interest rates by 4.25 percent within a month of the lockdown (the rate presently stands at 7 percent) to incentivize employers to retain workers and pay their wages. Other concessions provided by the state bank include schemes such as concessionary refinance and extension of loans.

However, the state has demonstrated barely any sensitivity to gender in policy design, despite the aforementioned disproportionate effects of the virus and preventive measures on women. The National Action Plan for COVID-19 has no recognition of gendered or intersectional impact in either its goals or its objectives. Without recognition, it is unlikely actual action on the same will materialize. This is already evident from the lack of female representation on the various committees established to implement the plan. One research found women represent only 5.5% of these committee members nationwide, with a total of 253 men and only 14 women in COVID-19 response committees. Trans people, although now with rights on paper, are completely absent from these plans and bodies.

There are no economic concessions targeting women, such as financial schemes for female entrepreneurs or public procurement of items such as personal protective equipment from women-led businesses. In fact, there is little to no evidence available on the implementation and positive impact of existing concessions. The Pakistan Industrial and Traders Association Front (PIAF) has said that there is “zero implementation on directives of the government” and instead a refusal to offer loans and implement refinancing schemes with several small and medium enterprises suffering. Such a failure of implementation means even if a gendered and intersectional lens is employed in design, there is little hope for its benefits materializing.

Perhaps the only pro-women policy by the government is the Ehsaas program, established by the government’s Division of Poverty Alleviation and Social Safety as a new poverty alleviation mechanism in 2019. A reformation of the Benazir Income Support program, Ehsaas Kafaalat provided women from very poor families a monthly stipend of PKR 2000 for 4 months beginning February 2020. Although more updated and accessible than its predecessor, the Kafaalat program still requires significant changes to benefit the female population. This is because the program requires a notable degree of access to digital and financial resources such as cellphones, bank accounts as well as IDs, most of which are disproportionately unavailable to women in Pakistan. Additionally, the program relies on the 2011 National Socioeconomic Registry (NSER) that is yet to be updated. This means no COVID-specific targeting has been done under the Kafaalat program. Since the targeted households are the poorest of the population they are likely to be largely in rural areas while the virus hotspots are mostly identified in big cities. So, although the program’s funds will benefit recipient women, these benefits are less likely to reach women significantly impacted by the virus. The categories of the umbrella Ehsaas program addressing the new poor (II and III) do not target women specifically.

For Pakistan to truly recover from the pandemic, a holistic and intersectional approach needs to be adopted towards remedial strategies. Existing research and literature provides several examples that can serve as replicable models for the country. Economic Crises and Women’s Work, a report by UN Women, provides the examples of Argentina and Sweden, two countries whose crisis response was sensitive to women’s employment conditions. In Sweden, this involved strategies such as direct public employment for women as well as educational and vocational assistance. Such strategies can be incorporated into existing programs like the government’s employment generation scheme “green stimulus” and provincial vocational training centers. More importantly, Sweden’s policies were not limited to isolated labor market interventions but involved a broader macroeconomic strategy that cultivated better quality jobs and decent living conditions. On the other hand, Argentina’s example emphasizes another important aspect of recovery; administrative and legislative changes, such as enforcement of minimum wages and mechanisms to ensure compliance. Moreover, a strong welfare state and collective bargaining mechanisms, especially for vulnerable groups at the bottom of the wage pyramid, is crucial for managing any crisis and its aftermath.

Equally crucial for policy design, both during and after the pandemic, is the collection and dissemination of gender disaggregated data on Covid-19.  A contextual analysis of such data allows for more nuanced decision making. Furthermore, an analysis of Ehsaas Kafalaat identifies solutions such as delivering funds directly to women as a first step in addition to other mechanisms including giving priority to applications submitted by women. These approaches allow program benefits to reach more women and pave way for further action. Finally, health and safety are crucial for survival and policies must address the atrocious neglect women face in accessing quality services. Pakistan can also explore innovative solutions during the pandemic such as in the Netherlands, where midwife teams are utilizing closed hotels to provide maternity care. Of course, all such solutions require care and precautions on part of the practitioners.

These examples point to the various possibilities for gendered approaches to the pandemic’s management. Pakistan’s female population makes up almost half of its total. Neglect of women in any policy will have dire consequences for the country as a whole. As Pakistan’s Covid-19 battle seems to ease and attention turns to recovery, it is imperative that women – especially those belonging to vulnerable groups - are centered in policy design and implementation.

Tuesday, 8 September 2020

The land is eager to teach

by Haris Gazdar

image by Asif Hassan/AFP

“If consciously or otherwise you were brought up believing that Karachi in 1947 was "a land without people for a people without land" this must be a disturbing time for you.  Commiserations.
 And if in your imagination Karachi was not part of Sindh, commiserations again. Check Google Maps. What is Karachi? A settlement on the sea shore, occupying land between the Hub and Malir Rivers, to the north of the farthest reach of the Indus delta.
You assumed, without ever caring to actually know, that you were entitled to the water that flows down the Kirthar Range, and the Indus, but only if it comes in taps. Commiserations. Water flows down. Sometimes taps come in the way. Sometimes not.
Urban planners duped you into assuming that the land, its rocks, hills, riverbeds, bushes, backwaters, mangroves, the sea, its tides and currents don't matter. Omnipotence of civil engineering. Commiserations.
You need to lash out. Of course you do. From omnipotence to impotence. What else will you do? The word Sindh, forget Sindhis for a minute, the word Sindh, it strikes fear because it shatters the fiction of omnipotence. Commiserations, and compassion.
Take time out. Let things settle. A crime has been committed. Relax, you are not the criminal. But you are not the most wretched victim, certainly not the only one. Let it sink in: there is no land without people, there are no people without land.
You are not impotent, omnipotence was an illusion. The fear is understandable. Let it pass. Sindh will irk you less. Sindhis too. The land is eager to teach, through people who have given it the time, their stories stores of knowledge, wisdom even, will make you powerful again.”
This post is adapted from a Twitter thread by the author published on 2 September, 2020. Follow @CollectiveKHI and @HarisGazdar to stay up to date with analysis and insights on current news in Pakistan and South Asia.

Monday, 24 August 2020

Populist Policy not Effective Reform: Why Amending Pakistan’s Drug Pricing Policy is a Mistake

By: Kabeer Dawani 

Earlier this month, the Federal Government of Pakistan amended the Drug Pricing Policy of 2018 in a bid to reinstate the government’s control over medicine prices and end automatic, inflation-adjusted increases. This follows public outcry in January 2019 over price increases and ongoing debates around affordable healthcare in the wake of the COVID pandemic.

Medicine pricing has long been a controversial issue in Pakistan. Currently all pharmaceuticals have strict price ceilings, which, combined with a policy of price rigidity, has incentivised manufacturers to set very high initial margins. As a result, consumers face overpricing, shortages of drugs that are no longer profitable to manufacture, as well as poorer quality and less effective substitutes. While the Drug Pricing Policy was welcomed by many in the industry as a way to regulate an otherwise ad-hoc process, medicine pricing remains a populist issue and politicians face pressure to keep prices low.  

For the past two years in partnership with the SOAS Anti-Corruption Evidence research consortium, I have researched the Pakistani pharmaceutical sector, with a focus on rent-seeking related to pricing. In two papers coauthored with Asad Sayeed, I discuss the political settlement of Pakistan’s pharmaceutical sector and issues of pricing, procurement and quality.

So, why is pricing of medicines so contentious in Pakistan? Do the strict price controls have positive or negative consequences? And can the pricing regime be structured in a way that benefits both the industry and the consumer?

Populism in pricing

Pakistan has implemented strict price controls and rigidity on medicines despite not having a clearly defined price-setting policy until 2015. From 2001 to 2013 there was a virtual price freeze on medicines. And even in 2013 when the Nawaz Sharif government increased prices, the decision was reversed within a matter of days due to public pressure. Pharmaceutical firms subsequently pursued a series of court orders until price increases were granted and a pricing policy was instituted, first in 2015, and then again in 2018.

The 2018 drug pricing policy was formulated after due consultation with relevant stakeholders – nearly all of the people interviewed for our study supported it. The policy rationalises what was previously an ad-hoc process of price determination and increases, which one manufacturer termed as a ‘negotiation’ with the government. Under the new policy, increases were granted based on inflation – such as for essential medicines which could be increased by 70% of annual inflation once a year.

However, early in 2019 there was public uproar over approved price increases that I have previously argued were largely legitimate. At the time, the Imran Khan-led government came under considerable pressure by the media and the then-federal health minister, Aamir Kiani, was removed from office for alleged corruption in granting the increases. In May 2019 the new health minister, Dr Zafar Mirza, was tasked with reducing these prices within 72 hours and, by the start of 2020, the government had reduced the prices of 89 medicines by 15%.

This month the government has revoked the inflation-based price increases and has reinstated the Drug Regulatory Authority of Pakistan’s (DRAP) arbitrary powers to decide increases – which must be seen in the broader context of strict price controls. Every government, across parties and systems, has continued with the populist policy of restricting increases because any change in the price of medicine – an essential good – is perceived as a failure of government and anti-poor. But populist debates often ignore the wider ramifications of the price controls.

What do price controls mean in reality?

The strict price controls increase the production costs of drugs, which means that pharmaceutical manufacturers employ multiple mechanisms to continue to grow and profit.

Firms secure very high initial prices – sometimes with margins of 1000% – because they know that these will be squeezed over time. There are also inevitable shortages if a medicine is not profitable to produce (one study found that only about a third of essential medicines were available in the market), while higher-priced substitutes may be introduced and produced that are more economical for manufacturers. Due to lax regulation, firms routinely compromise on minimum production standards (‘Good Manufacturing Practices’ or GMPs) too that are a necessary condition for quality medicines, in an effort to secure higher profits.

Although hard to quantify, consumers will experience negative health effects from sub-standard drugs – they have to consume medicines for longer due to their lower quality and may not be able to access essential medicines at all due to their unavailability. Patients may also experience complications from the drugs shortages and slower treatment due to lower efficacy. Consumers have to spend more on medicines too – our research shows that for the poorest 10% of the population, expenditure on medicines as a share of total health expenditure nearly doubled from 45% in 2010–11 to 80% in 2015–16.

So the stated aim of price controls – to keep prices in check so medicines are affordable for low-income households – is directly contradicted because of the incentives created for firms to circumvent the restrictions. And the consequences described above are harmful for the broader population, disproportionately affecting the poorest in Pakistan.

Strategies for reform  

In the Democratic primary campaign in the United States, Bernie Sanders and Elizabeth Warren consistently highlighted exorbitantly high drug prices as an issue. Left alone to capitalist forces, prices for medicines can skyrocket. However, at the other end of the spectrum, Pakistan’s strict price controls demonstrate harmful consequences in developmental terms.

A balance needs to be struck of course, and Pakistan’s Drug Pricing Policy of 2018 as originally devised was a step in the right direction in establishing clear rules for rational pricing. As a result of the latest amendment this month, the current government may undo the beneficial aspects of the 2018 policy and they should seriously reconsider their decision.

A large body of political economy research suggests that top-down policy changes are difficult to initiate and implement. Instead, successful improvements can be achieved through horizontal changes by industry or other players in the economy – policy-makers and industry stakeholders in Pakistan should take heed.

Our study suggests that a feasible way to seek improvements in pricing and access to medicines is if pharmaceutical firms and the media can work together. The media in Pakistan has significant power in shaping public discourse and opinion. But, due to the complexity of the pharmaceutical sector and the relationship between pricing and larger public health concerns, reporting has been inadequate and often misplaced. The media, in fact, reinforces the populist pressure on governments to suppress medicine prices.

And so the onus is on the pharmaceutical sector to work with the media. One possible way to do this is through independent journalism schools who organize workshops to train journalists. The industry can finance these schools, who can then organize workshops for journalists on the impact of price controls on social welfare and the broader effects beyond populist debates. The trainings will be credible because they will be conducted independently and not the industry, who will not have any editorial input. This is crucial for the strategy to be successful, and some schools do presently organize journalists’ trainings through corporate financing, so it is not unprecedented. Thus, if the print and electronic media can report more critically and highlight the harmful impact of rigidity in medicine pricing and its ad hoc nature, it could be possible to decrease incrementally public opposition to price increases.

In turn, informed public attitudes will allow politicians to enforce consistent, rule-based price increases. Not only will this reduce drugs shortages, it will also reduce the high margins on medicines and the propensity for higher-priced substitutes. Although such efforts will take time, this is one feasible way for meaningful reform in the pharmaceutical sector and for improvement in access to medicines in Pakistan.

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

This essay was first published by Naya Daur Media and is reproduced here with the author’s permission.

Monday, 6 July 2020

Lives and Livelihoods: The Inevitable Defeats of Pakistan’s Poor

A family of 7 live in a one-bedroom home in machar (mosquito) colony, a slum in Karachi during a 3-day lockdown on March 22, 2020.
Saiyna Bashir for The New York Times.

Pakistan’s first Covid-19 case was confirmed in late February. Over the next four months, and amidst varying responses to the virus, Pakistan has emerged amongst the countries most affected by the pandemic. Classified as a lower middle income country by the World Bank, it faces an exacerbated impact of the virus due to various factors, including poor infrastructure, limited resources, as well as bureaucratic inefficiencies and political instability.
In addition to a public health crisis, Covid-19 has created interrelated demand and supply shocks for the economy where various sectors are witnessing declining production and consumption, leading to negative impacts on income and employment. Coupled with disruptions in global supply chains and failures in the healthcare system, these shocks have devastating economic and social consequences. Such consequences have contributed significantly to Pakistan’s lockdown debate, where proponents argue that lockdowns reduce transmission and consequently prevent a surge in infections and possible deaths while opponents assert that the loss of livelihoods resulting from these measures starve the poor and have far worse economic outcomes.  
However, in examining the pandemic’s effects on private consumption of the Pakistani population in general, and for lower-income households in particular, this blog shows that Pakistan’s poor are likely to lose out irrespective of a lockdown as incomes and health are both  compromised. Pakistan needs to divert focus away from the incorrect dichotomy pitting lives against livelihoods and towards evidence-based policies in order to effectively combat the virus while also protecting its most vulnerable population.
Changes in Consumption
Covid-19 has caused significant changes in consumer behavior, which are both a catalyst as well as an outcome of the aforementioned market shocks. As income sources become precarious or lost, demand falls in turn putting further strains on income. In a recent article, John Mullbauer predicts that the United States’ quarterly consumption is likely to fall faster than income, by approximately 20%, due to Covid-19. A similar impact can be anticipated for Pakistan’s economy given the Federal Government’s  perplexed Covid-19 response and the continuing surge in infections. Pakistan’s poverty rate is estimated to rise up to 33.5%  and falls in private consumption are expected, particularly for more vulnerable sectors such as recreation and restaurants. Overall spending will also suffer since online shopping is unlikely to compensate the fall in demand due to lockdowns, at least in the short run. On the other hand, spending on food eaten at home and healthcare is anticipated to rise. Some analyses have reported a 66% decline in the amount spent on eating out while a 70% increase in the amount spent on groceries in Pakistan. With the shift to working from home in partial or complete lockdowns, spending on transportation and fuel is likely to go down as well while there will be potential rise in demand for better telecommunication services and online shopping.
As consumer behavior adjusts to the changing circumstances in Pakistan, the poorer households become the worst hit by the pandemic, where consumption decisions are also influenced by larger realities such as the absence of adequate social safety nets. Carolina Sánchez-Páramo, a World Bank economist, explains that the poor suffer more owing to greater vulnerability arising from factors such as location, with many of the urban poor living in close quarters where social distancing is difficult if not impossible to achieve. In Pakistan, this is evidenced by the high number of cases from such areas, particularly Karachi’s informal settlements and slums, where residents have spoken about the impossibility of social distancing owing to living arrangements. For lower-income groups, this vulnerability is further aggravated by a greater dependency on public services, where the exponential growth of the virus further encumbers the healthcare system and many poor households find themselves with limited or no access to quality healthcare. For Pakistan, the health risks magnify as a majority of the lower income population depends on public transport, where several people cram in one vehicle and following ‘standard operating procedures’ becomes impossible.
Perhaps the greatest cause of vulnerability for lower-income households arises from their sources of income. Low-income workers are often employed in informal, vulnerable and non-permanent jobs. The Labor Force Survey 2017-18 reports that 72% of non-agricultural employment is in the informal sector in Pakistan. Workers in these sectors are not covered by the state’s social and legal security and can be easily laid off. Reports claim that massive layoffs are already occurring in Pakistan and, according to the Ministry of Planning and Development, estimates suggest up to 18 million Pakistanis could lose their jobs as a result of coronavirus shocks to the economy.
These circumstances are not restricted to informal employment alone. According to the Pakistan Bureau of Statistics, 55% of the labor force across sectors is engaged in vulnerable employment. With declining demand, these workers are prone to job losses and unstable incomes. Restaurants and Hotels, a sector gravely impacted by Covid-19, has a vulnerable employment share of 48%.  The Pakistan Tourism Development Corporation has recently fired all regular employees of three of its companies due to continual losses and the ongoing pandemic’s effects. Data from the Labor Force Survey 2017-18 shows that a majority of Pakistan’s labor force is employed in Skilled Agricultural & Fishery, Services and Sales, Elementary Occupations and Craft and Related trades. The same occupational groups are also the ones with the lowest average monthly wages, with the lowest recorded for Elementary Occupations. These jobs are largely constituted of daily wage workers such as street vendors, domestic helpers, waiters, textile and garment workers, etc. who are unable to earn in case of a lockdown. Even without the lockdown, incomes continue to suffer due to the threat of contagion with most markets deserted and demand compromised. These workers also face greater health hazards due to the nature of their jobs and are more susceptible to contracting the virus.
Commanding a greater vulnerability, Pakistan’s poor adjust consumption in significantly different ways that have serious consequences. Using expenditure data from the Household Integrated Economic Survey (HIES) 2015-16, we calculated that food constituted almost half of total expenditure for households belonging to the lowest percentile groups of income in Pakistan. Other major expenditure groups included imputed rent, clothing, electricity and fuel. The expenditure groups that faced an automatic decline in spending due to the virus, such as Restaurants and Hotels, Recreation and Culture and Transportation, constitute a minor proportion of the expenditures of lower-income households (between 2 to 4%).  Thus, falls in income could mean these households adjust consumption with reductions in spending on food and other necessities, which has significant implications for their nutrition and long-term human capital development. In  Pakistan, where already 38% of the children under five are stunted and 23% of all children are underweight, these ramifications will likely be worse.
Policy Responses
The government has attempted to redress this alarming situation with cash-transfers through the Ehsaas program and income generation through paid ecosystem nourishment of the “Green Stimulus” program. At the same time, several non-governmental organizations are also providing assistance to the vulnerable during the pandemic. However, an adequate response requires concerted efforts by the state beyond short-term relief mechanisms. Some important factors to consider include the recognition of the need for substantial fiscal resources, timely delivery of support packages and cognizance of the new poor that are absent in existing programs. Moreover, an efficient and well-designed welfare system becomes crucial to mitigate the long-term impact of Covid-19. Unfortunately, such a creative effort seems missing from the recently announced Federal budget for 2020-21.
As Pakistan falters in formulating a coherent and effective response to the virus, several Pakistanis go to bed hungry and several others struggle to receive healthcare while the debate on lives or livelihoods persists. However, an examination of the situation demonstrates that Covid-19 has serious effects with and without the lockdown. A response that constructs a binary between lives and livelihoods is faulty. Life necessitates livelihoods and livelihoods sustain lives. An effective response to Covid-19 must address these in conjunction and not separately. The state needs to prepare for both short and long-term consequences of the virus and concentrate efforts on saving both lives and livelihoods, especially for its most vulnerable people that are, unfortunately, the ultimate losers in this pandemic.

Wednesday, 10 June 2020

On the Frontlines: The Strain on Healthcare Providers

By: Komal Qidwai

A Covid-19 Ward at Civil Hospital, Karachi. Photo Credit: Health and Population Welfare Department, Sindh
As Pakistan’s Covid-19 tally rises above 100,000, hospitals across the country are running out of capacity and the burden on frontline providers is growing. Through our interviews with experts and on-going tracking of news and social media content, we have identified some major areas of concern regarding the safety and rights of frontline healthcare providers.

Starting in May, a stream of violent attacks began against healthcare providers and facilities by angry relatives of patients. In two separate violent incidents in Karachi’s Jinnah Postgraduate Medical Centre (JPMC) and Civil Hospital, relatives of deceased coronavirus patients demanded the release of their dead bodies, with the mob in the latter facility denying that the deceased was Covid-19 positive. Both groups of attackers damaged the facilities, breaking the glass windows on counters and throwing around furniture. Family members of a deceased patient also stormed into the hospital’s isolation ward and hurled abuses at the staff before attacking and injuring a young doctor in JPMC. In Peshawar’s Lady Reading Hospital, relatives of a 50-year-old corona patient broke down the door to the Covid ward and brawled with the doctors when they were informed that she died.

One reason for people to attack healthcare facilities and demand the release of dead bodies is denial that the pandemic is real. Near the end of April, Gallup Pakistan reported that over 3 in 5 Pakistanis believe that the coronavirus threat is exaggerated.

As hospitals run out of beds, ventilators and other equipment, frontline healthcare providers report high levels of stress. Even providers not directly dealing with Covid-19 cases are under strain and report constant anxiety. “Patients are being very rude and aggressive these days. Before the pandemic, incidences of aggression or violence happened rarely, but now it’s become a daily occurrence”, says senior gynecologist and obstetrician Dr Azra Ahsan. Providers are at risk of contracting the virus, as well as violence from angry family members of patients.

Over 2200 healthcare providers—1240 of whom are doctors—have been infected with the coronavirus, and 24 providers have died, including 15 doctors. Frontline providers report that facilities are now short-staffed because so many doctors and staff members are falling ill.Doctors had warned that infection would spread fast in the healthcare community due to shortages of personal protective equipment as well as lack of guidelines on its use. They complained that corona wards in hospitals were not disinfected properly. Healthcare providers also reported that private facilities were not providing their staff with PPE, risking their safety and lives. Young doctors have had to turn to non-governmental organizations (NGOs) for protective equipment supplies.

Doctors in Sindh urged the government to enforce stricter lockdown measures; pleading that people should stay at home and explaining that the situation in healthcare facilities was dire.

But government response has been mixed at best. In Quetta, the authorities refused healthcare providers’ demands for the provisions of PPE, and medical staff’s protests were met with police baton-charge and arrests. In Sindh province, doctors protested to demand PPE provision for all providers as early as the end of March, but to no avail. In Peshawar, two doctors resigned from Lady Reading Hospital in protest, claiming that the facility was not adequately equipped to deal with Covid-19 cases and healthcare providers were at risk. In Lahore, doctors of the Grand Health Alliance held a sit-in despite police threatening to charge against protestors. Over two weeks later, the government finally agreed to negotiate with the protestors, who were demanding PPE, regular screening of healthcare providers, and a risk allowance.

Doctors report the increasing number of staff falling ill combined with a lack of sufficient resources will now impact the quality of care being provided in healthcare facilities. Despite the worsening situation of healthcare facilities, the rising number of cases, and pleas of healthcare providers, the federal government is not considering re-imposing the lockdown. During a recent press briefing before a meeting of the Covid-19 National Coordination Committee, the federal Minister for Planning and Development, Asad Umar, remarked that the government would only impose a lockdown when the healthcare system gets overwhelmed.

Healthcare providers believe the system is already overwhelmed when even a cannula is not available for the treatment of a doctor sick with Covid-19. Families and colleagues of doctors in Karachi, Lahore and Multan have claimed that their loved ones have died from Covid-19 due to negligence of healthcare facilities and staff. The Special Assistant to the Prime Minister on Health, Dr Zafar Mirza, still claims only 30 percent of hospital resources dedicated to Covid-19 are being used. While the government has decided to provide 1000 additional beds with oxygen facilities in light of the burden on hospitals, there is no mention of the shortage of staff to provide care.

The strain on the healthcare system is not only impacting Covid-19 wards and patients but all other departments, including maternity units. Even in early May, Peshawar’s Lady Reading Hospital and Islamabad’s Pakistan Institute of Medical Sciences (PIMS) had to close their maternity wards due to the high number of infections among staff. Dr Nusrat Shah, a senior gynecologist at Civil Hospital in Karachi, reported they regularly received pregnant patients seriously ill with Covid-19. Despite these warnings, the government started to ease the lockdown in early May.

As the situation worsens, we can expect reproductive healthcare services will become more severely affected due to the strain on healthcare providers.Pakistan’s curve shows no signs of flattening; the government and the families would do well to remember that healthcare providers are risking their lives to provide services to their patients.