Healthcare in 2021
Dr. Safieh Shah, MPH
Altaf M.D., MPH
The government’s response to COVID-19 is unlikely to improve with the introduction of a vaccine in 2021; not in our current public health environment. Identifying deficits in Pakistan’s public healthcare system is required to understand how our healthcare response can do better, especially when it comes to the representation of multiple ethnic groups. This is the only practical means to ensure that public health knowledge and COVID-19 vaccination are both accepted by Pakistani citizens.
Pakistan’s response to COVID-19 has been confusing, inadequate and reactive. It has not served the citizens well. While a case for Pakistan being caught unawares can be made, like most other countries, the ‘second wave’ has brought about increased awareness and information about the virus. However, policymakers are continuing to act in the same reactive manner without scientific basis for recommendations.
To be sure, Pakistan’s healthcare delivery system is poorly organised, inadequately managed and resource constrained. Introduction of the vaccine with such a system, will reflect the shortcomings of the system itself. Gleaning from the evidence related to other vaccine programmes, such as measles and polio, one gets an idea of how this is going to pan out. There remains a serious lack of technical capacity at the top; critically needed to design an appropriate system and to deal with epidemics. Looking at the WHO or CDCs for inspiration can only take us so far.
Lack of information about the government’s plans, misinformation about the disease and the use of vaccines for protection make the task of vaccination difficult. Add to that the lack of trust in authorities—demonstrated by continued vaccine avoidance—the state might find it challenging to administer regular and widespread doses to control the spread of infection.
Even with the constraints and challenges in place, there is much that the government can do even now. A thoughtful, comprehensive strategy appropriate to the needs of our population, with well-planned activities should be put in place. Imitating another country’s response or seeking donors’ help for a catch-all solution will not resolve our long-term challenges. It is equally important to figure out methodologies for what needs to be done: centralisation is not a good idea—districts should be empowered (and funded) to plan, monitor and manage services at the local level with support provided at the provincial levels. 2020 was a difficult year for healthcare services in Pakistan; 2021 will pose similar challenges and potentially strain the capacity of policymakers and medical professionals alike.
India-Pakistan sparring in 2021
Relations between India and Pakistan will remain fraught in 2021, after a tense year that saw little progress in the relationship between the two countries and sustained diplomatic sparring. The risk of escalation of hostilities remains high, with both militaries on alert in the disputed region of Kashmir and elsewhere.
Since the 2019 military standoff following the attack against Indian security forces in Pulwama, it has become clear that India has sought to move the needle in terms of acceptable military interventions. Indeed, the Indian airstrikes on Pakistani territory in February that year came after the 2016 “surgical strike” following the Uri attack: the airstrikes were themselves an escalation of India’s new ‘normal’ for intervention.
Today, Pakistan is once again warning the world community of the possibility of Indian military attacks on Pakistani targets, based on what the foreign ministry and intelligence community is terming “specific and reliable” intelligence. It is of concern that Pakistan’s view of the potential crisis includes the fact that certain members of the international community were already made aware of the possibility of these attacks by the Indian government and did nothing.
The latest allegations come after Pakistan shared a new dossier of intelligence that purports to show direct Indian sponsorship of terrorism on Pakistani soil. India denied the allegations, and, days later, traded one allegation for another, alleging that it had foiled an attack on Indian security forces that had been planned in Pakistan.
For Pakistan, the evidence is “irrefutable”, but the true test will be how this dossier is viewed in world capitals. So far, the dossier appears to have done little to convince Western powers to change their approach to the region—which was the stated aim of the Pakistani initiative.
Both sides have currently set preconditions for talks that the other simply will not meet. Pakistan demands the reimplementation of Article 370 and a withdrawal of restrictions on Kashmiris, while India wishes Pakistan to accept Indian-administered Kashmir’s new status and move forward from there. The positions are, currently, irreconcilable, with little flexibility. The domestic political climate in both countries, too, would also appear to preclude the possibility of any direct talks in the near future.
The recent swift trading of allegations between the two sides, with little in the way of any direct or Track II dialogue, suggests that 2021 will be a year of dangerous brinkmanship, where both sides will continue to raise the temperature on tensions while focusing their energies not on talking to each other, but to the world community about each other.
The most visible victims of this continuing lack of engagement will be the people of Kashmir, where thousands of Line of Control ceasefire violations by both sides—each blaming the other for initiation—have killed dozens and left hundreds more wounded. The majority of those killed are in Pakistan-administered Kashmir.
In Gilgit-Baltistan, with a new political and military consensus on according provisional provincial status, expect 2021 to deliver a constitutional amendment in Pakistan’s parliament that would accord greater powers of self-rule to the GB government, absorbing the territory into Pakistan’s administrative and governance mainstream. Pakistan’s careful messaging around this development, with a focus on how it is both in response to the demands of the people of GB and will be subject to all relevant UN Security Council resolutions, suggests that Pakistan is serious about pushing forward with this initiative.
Democracy in 2021
Pakistan’s long-running tryst with authoritarianism showed no sign of abating in the year 2020. In fact, a little over two years after taking power, the PTI government is embroiled in a crisis of legitimacy, growing criticism of its performance coupled with the perception that it is essentially operating at the behest of the establishment. A government that came into being with promises of creating ‘Naya Pakistan’ is instead saddled with the label of ‘hybrid regime’ harkening more to the past than the future.
It remains to be seen whether the formation of the Pakistan Democratic Movement (PDM) in September 2020 will push Pakistani democracy in qualitatively new directions, notwithstanding the PTI government’s attempts to discredit it. In more than thirty years since General Zia ul Haq’s military dictatorship met its ignominious end, mainstream political parties have been engaged in what is effectively a zero-sum game, vacillating between compromised stints in government and exclusion from establishment patronage in the opposition. While there was cause for optimism in the completion of full terms in government by both the PPP and PML-N between 2008–13 and 2013–18 respectively, the hypothesis that continuity in the electoral cycle represents substantive democratisation of the polity remains on shaky ground.
It is in this context that the 11-party PDM alliance represents the latest attempt to transform the establishment-centric political system. In this sense, the PDM’s objectives would seem to mirror the Charter of Democracy (CoD) signed in 2006 between Nawaz Sharif and Benazir Bhutto while both were in exile. There is reason to be sceptical, however, that such lofty ambitions can be achieved; in almost fifteen years since the CoD, the common front presented by mainstream parties in their ostensibly anti-establishment quest has broken down time and again.
In the final analysis, Pakistani democracy will continue to flounder in the absence of a struggle which incorporates a wider cross-section of society. The PTI government has overseen a clamping down on the media, as well as social movements in the long-suffering ethnic peripheries, and amongst youth and women more generally. A broader democratic movement bringing together all of these civil rights struggles with political parties can constrain an omnipotent establishment, historically as powerful as political parties have allowed through their own disorganisation and in-fighting. At yet another crossroads for Pakistani democracy, the forging of unity is once again imperative.
Education amidst the pandemic
2020 was defined by COVID-19 and became one of the reasons that kept education in the national headlines. Academically, the year was marred by repeated school closures. For most students these prolonged closures resulted in disengagement from learning. This, according to some estimates, has set back their learning by months and is projected to significantly reduce their lifetime incomes. A proven solution to address learning losses is by remedial classes—grouping and teaching students according to their proficiency level. 2021 may be the year we will see the federal and provincial governments step up and meet this challenge with the resources it demands and get students back on track. The alternative will be an attempt to act ‘normal’ and see an even greater than usual number of students fall behind, get frustrated and ultimately drop out of school earlier than they need to.
The differences between the way high-end private schools and all other schools handled school closures laid bare the digital divide. The government is developing a distance learning strategy but like all policies this one too will only do any good if the words put on paper are backed by necessary investments to expand broadband coverage, access to devices and effective delivery of online and broadcast instruction.
The second education issue which drew attention during the Spring and Summer was the leak, and later official release, of the Single National Curriculum, or SNC, for grades 1 to 5. The SNC issue attracted an unexpected level of public interest and debate. Unaffiliated education experts from civil society contributed their independent and critical analysis to the public debate, bringing up questions about the closed process by which the SNC was developed, its scope (public vs public and private schools) and implementation that elicited clarifications from the government. In 2021 we will see the roll-out of the SNC in primary schools, the release of the first textbooks, and the development of Phase-2 of the SNC, which will cover the curriculum of middle school grades. If this year’s debate is anything to go by, the SNC’s next instalment will generate a similar level of public scrutiny and engagement.
Another item on the government’s to-do list is the formulation of the new National Education Policy, or NEP. Work on the NEP has just started and will pick up pace in 2021. In typical fashion, we put the cart before the horse and developed the SNC first when logically it should have followed the more encompassing NEP. From what we know so far, the policy formulation process is ad hoc, driven by the intuitions, whims and anecdotal experiences of individuals, rather than evidence and an institutionalised policy formulation framework. Without careful consideration of cost, allocation of resources and an implementation mechanism, the policy document will only be a check box exercise.
Pakistan's search for growth in 2021
In the year 2021, Pakistan’s search for a path back to economic growth is set to intensify. The country’s growth rate crashed in FY2019, falling to less than 2 per cent, near the same level it was at in 2010. In the closing months of 2020, some green shoots of an economic revival did begin to sprout as some high frequency indicators, especially in large-scale manufacturing, showed an uptick in activity, and the external account maintained a surplus and foreign exchange reserves continued to strengthen. But this nascent revival had been purchased at a large cost in handouts extended to manufacturers and exporters in the shape of subsidised credit, power and fuel, as well as generous tax and duty reductions. In the year 2021, the country seeks to resume its IMF programme that was suspended in April when the COVID lockdowns began. It remains to be seen how many of these ongoing handouts will continue once the programme resumes, and what happens with interest rates that are already on the lower end of the band of projected inflation. If the Fund programme necessitates a withdrawal of the handouts, a hike in interest rates and renewed focus on revenue generation and deficit control rather than economic stimulus, the nascent growth seen in the closing months of 2020 could be in jeopardy.
The biggest hit of the ongoing adjustment and lockdowns has been borne by the most vulnerable groups in society, especially the poor. Even before the lockdowns, some estimates said more than 2 million people had been rendered jobless, but after the lockdowns another estimate projected more than 18 million job losses. Precise figures are not available, but enough evidence had accumulated by the close of 2020 to suggest that unemployment is one of the biggest stumbling blocks plaguing the economy. Add to this the food price spiral that returned in the winter of 2020 with a renewed ferocity, and you have a very grim picture for the poorest segments of our society.
This combination of rising job losses and spiralling food prices have exacted a terrible toll from the poor. Whether 2021 can meaningfully reverse this is one of the biggest questions facing the government. One big opportunity that opened up during the period of lockdowns was the sharp rise in digital tools, including for payments. In the opening months of 2021, the government has the opportunity to leverage mobile payments and the sharp increase in data usage by mobile users, to build superior targeting technologies to reach the poor. Instead of handouts for the rich, the same money can be credibly diverted directly to the poor, from where it can percolate up in the form of demand and help drive the engines of the economy.
Pakistan's FATF experience
Pakistan’s ‘grey-listing’ by FATF in June 2018 led the global money laundering and terrorist financing watchdog to develop a 27-point Action Plan aimed at remedying the structural deficiencies in Pakistan’s Anti-Money Laundering/Combatting the Financing of Terrorism (AML/CFT) framework. This was the third time since 2008 that Pakistan found itself on the FATF ‘Grey-List’ and its initial response comprised of a mixture of law enforcement operations and the creation of governmental bodies and taskforces to promote inter-agency coordination and policy implementation. However, it quickly became apparent that FATF’s new Enhanced Expedited Follow-Up regime demanded comprehensive and definitive progress by Pakistan on all action points. The response by the Pakistani state to this new reality over the past 30 months is characterised by its attempt to adopt a holistic, whole-of government approach encompassing legislative and administrative reform, technical capacity building through trainings, development of guidelines and inter-agency coordination.
Currently Pakistan is deemed compliant on 21 out of 27 actions points which is a commendable achievement. Central to this effort was extensive legislation on key areas of the FATF Action Plan. Between February 2020 and October 2020, Parliament passed 15 pieces of legislation, amending key statutes such as the Anti-Terrorism Act, 1997 (ATA) and the Anti-Money Laundering Act, 2010 (AMLA) to ensure that legal cover was provided to FATF’s Action Plan and its 40 Recommendations.
With the appropriate legal and regulatory frameworks largely in place, the outstanding points now require Pakistan to ‘demonstrate’ efficacy against terrorism financing. Pakistan is required to ‘demonstrate effective implementation’ of its targeted financial sanctions regime, which means that proscribed persons and banned organisations must be prevented from raising and moving funds and their assets seized. Similarly, the criminal justice system must demonstrate efficacy in identifying, investigating, and prosecuting terrorism financing activity.
FATF’s emphasis on Pakistan’s ‘structural deficiencies’ and the need to ‘demonstrate’ efficacy prioritises an approach which is focused on institutional responses and automatic processes as opposed to ad-hoc, short-term and reactionary policy measures. On this front, the major challenge remains Pakistan’s criminal justice system itself, which is plagued with antiquated laws, procedures, and operational failures during investigation and prosecution. The nature of terrorism financing and money laundering today requires expertise in specialist investigative techniques and reliance on evidence that goes beyond traditional ocular testimony and confessions. Large-scale capacity building endeavours in AML/CFT are therefore the need of the hour for all justice sector actors across the country along with entities responsible for the implementation of targeted financial sanctions. Pakistan needs to heavily invest in revamping its domestic justice sector frameworks, which requires long-term planning and resolve from stakeholders.
The coming months will also bring political challenges for the government as it seeks to operationalise the new legal frameworks on AML/CFT. Most of the recent legislation was rushed through Parliament to comply with FATF deadlines. In the process however, many of the stakeholders affected by these new laws were bypassed from consultation. A key area to watch are Designated Non-Financial Businesses and Professions (DNFBPs) which include lawyers, accountants, real estate agents and jewellers. These sectors are now subject to stringent record keeping and reporting requirements under the amended Anti-Money Laundering Act 2010 which are likely to have a significant economic impact and can result in political backlash. Similar concerns exist for regulation of charities and non-profit organisations. The government in Pakistan may find itself in an unenviable position as it seeks to balance FATF’s increasingly stringent compliance requirements with a slow economy in a difficult political environment.
Pakistan’s FATF experience provides a fascinating insight into the rapid evolution of international law and its implementation through ‘task-forces’ which are not based in treaty law yet are proving to be much more efficacious. However, this experience has also provided Pakistan with an opportunity to contribute to the evolving global frameworks on AML/CFT which must be capitalised on in the coming years.
Twilight hour in Afghanistan
For Pakistan, the imperative of building a more robust bilateral equation with Kabul will be followed closely by watching how talks between the Taliban and the Afghan government play out in Doha. A protracted intra-Afghan dialogue carries major risks for Afghanistan’s civilians, including its women and children, who bear the brunt of violence on the battlefield. It also carries risks for Pakistan, whose stakes in an end to violence are second only to Kabul’s, and whose policymakers are no stranger to the challenges emanating from an unfinished endgame next door. These challenges include (but are by no means limited to) the reputational costs from years of having been accused of having a silver bullet but not using it; the tendency of factional power centres in Kabul to lash out at Islamabad in service of domestic political agendas; and the omnipresent threat of revitalised TTP and Daesh sanctuaries on the Afghan side of the border.
Meanwhile, the drawdown of an additional 2,000 U.S. troops by mid-January, which will leave behind a reduced footprint of 2,500 soldiers, could go either way. It may incentivise the Taliban to keep their end of the bargain and reduce violence; concurrently it could persuade intransigent battlefield commanders to go for the kill. A key factor in the mix in 2021 will be the amount of diplomatic and economic leverage the international community retains in Afghanistan, and how this is put to use. In the absence of US domestic political interest in the last of America’s “forever wars”, this leverage, will likely have a short half-life unless Afghan parties quickly reconcile key differences and commit to a shared future of peace and rebuilding a war-torn nation.
Against this catalogue of challenges, what can, or indeed should Pakistan do? The first is it must stay the political course with Kabul. High-level engagement between the two sides is important, but so is routinised follow-through working groups on security and economic cooperation. Both Pakistan and Afghanistan stand to gain from regional cooperation and economic connectivity all the way up to the Central Asian Republics (CARs). Expediting work on a preferential free trade agreement (PTA) with Kabul could give a much-needed fillip to more ambitious blueprints for regional connectivity infrastructure. Secondly, Pakistan must swiftly prepare to deal with a new Biden administration after January 20.
The Joe Biden administration is likely to approach Pakistan from a 2016 prism: Pakistan needs to proactively update its talking points to communicate the extent to which the region has shifted on its axis, including the kinetic threat Pakistan faces from both western and eastern spoilers, and subterfuge exercised by New Delhi in a bid to upend outcomes that could otherwise benefit the entire region. Finally, Pakistan must carefully guard against the accusation that visits by the Taliban’s political commissions to Pakistan are indicative of the “leverage” that Pakistan retains. The extent to which Pakistan can help will always be a function of the weight which Kabul and Washington bring to bear on a negotiated settlement. That point must be made abundantly clear.
Pakistan's climate challenge
Advocacy targets are distracted. The pandemic has—at times—necessarily shifted priorities. In some cases, however, it has been used as an excuse. This has been particularly prominent in the global fight against the climate crisis.
It did not help that lockdowns gave way to a neat illusion. Reports of improved air quality could only catch up with what we could see outside our windows. Animals began returning to urban centres. Countless online posts stated that “nature was healing.” Then the headlines of reductions in greenhouse gas emissions came. It helped nudge an idea that perhaps we were in the process of mitigating the climate crisis.
Sadly, that mirage is nothing more than a trick of the light and global temperatures continue to be on the rise. Distraction from the issue does not make it go away.
In a world that is now increasingly looking inwards, climate policies are in more danger of being cast aside than before. It is critical that climate-vulnerable countries like Pakistan do not forget the strategic role it can serve in the global campaign to reduce emissions. Prime Minister Imran Khan’s recent announcement at the UN Climate Action Summit to ensure no more coal power plants are approved is an encouraging indicator that it has not.
However, the country must also look to its own climate governance. Generally, compliance with environmental standards and the adoption and implementation of adequate climate and environmental measures should not be seen in contradiction with the economic needs generated by the COVID-19 crisis. This is a critical reminder that must take centre stage in public discussions so that it does not provide a fig leaf for rollbacks being made on environmental gains.
The government must also recognise that human rights and fossil fuels are too disparate to coexist and must rapidly start phasing them out. The most marginalised and the most affected people must also be provided remedy for the disproportionate impacts of climate change on them. They must also meaningfully participate in any decisions that are taken that affect them and their way of life.
Not only must Pakistan urgently tackle the climate crisis but also do it in a fair manner, protecting, respecting, and fulfilling human rights. It must move away from exploitative, unsafe economies towards human rights-respecting economies that ensure freedom and equality and which remedy past and present human rights violations.
None of this will happen without the participation of the people. The political capital to be gained from decisive climate action will only come from localising climate change discourse. A regional vocabulary that conveys our lived experiences of the most devastating crisis of our lifetime must be developed. At least that way, we’ll know what is happening to us.