By Morial Shah

August 2011:

A tiny redbrick building stood where the narrow dirt road ended. Barefoot women and children waited inside. A few gunshots echoed in the distance.

We were in Shikarpur’s Lakhi taluka war zone, I was told. We were also in what was the only functional public building in Sindh’s kacho – the land between protective embankments and the shifting Sindhu River.

Traversing the boundary between formal and informal state power, the kacho occupies a complex and contradictory space.

It simultaneously serves as the focal point and antithesis of state control: Land records are deceptive; notorious Sindhi criminals - dharyals– mainly operate from there; and powerful stakeholders frequently resolve qaumi jhera or clan wars within its parameters.

By law, kacho land belongs to tenants—haris. But ground facts suggest otherwise: Kacho land belongs to people with bigger guns.

Successive governments have built schools, health facilities, and some police checkpoints for kacho residents to little avail.

Frequent feuds, fluid land records and concentrated criminal activities generally make it hard for these residents to access basic state services. However, there are a few notable exceptions.

The redbrick building in question was a Basic Health Unit (BHU).

When designing Pakistan’s health infrastructure in the 1970s, former Prime Minister Shaheed Zulfikar Ali Bhutto’s government expanded health coverage to Pakistani villages.

That scheme included Basic Health Units (BHUs) providing primary health services to villages, Rural Healthcare Centers (RHCs) offering health services to a cluster of villages, and Taluka Headquarter Hospitals (THQs) that were equipped to provide more sophisticated services.

Overtime – as trite as it sounds – these facilities faced what other social sector public facilities did: decay.

Imagine the Unicef team’s surprise, then, when we found ourselves taking shelter in a building that turned out to be an operating kacho area BHU. Women and men patiently waited to see the doctor. I interviewed twenty-odd Lady Health Workers who assemble there at the start of each month.

To state the obvious: a public health facility was functioning on the state’s peripheries – on kacha land, literally - while floods and feuds raged on nearby. Paradox, much? I’ve been trying map our fascinating contradictions ever since.

September 2014:

Fast-forward three years. As fate would have it, I found myself facing the man known as ‘miracle-maker’ in bureaucrats’ circles. In little over seven years, Dr. Riaz Memon changed the ground rules of Sindh’s primary healthcare.

Under his charge, the Peoples Primary Health Initiative (PPHI) made 83 per cent of the province’s BHUs fully operational (647 BHUs in total). And better still, they operate at less than 10 per cent of the district healthcare budget.

When asked about PPHI’s secret Dr Memon replied, “Two words: management and monitoring. Our strict auditing procedures and cost-saving practices set us apart.”

He further explained, “PPHI’s smart-phone monitoring system checks absenteeism. Detailed data entry in our District Health Information System (DHIS) plugs any leaks in our supply chain.

This makes our records exacting, transparent and easy to access. We are especially proud of our rigorous internal and external audit procedures. Only this past quarter, our internal audit team’s report led to our firing seven employees for culpable negligence.”

In addition, PPHI is proud of its cost-cutting methods. It generally buys local and international medicines at a fraction of the government’s purchasing price.

By way of an example, Dr Chandio, PPHI’s Health Services Director, cited how PPHI purchased Anti Rabies Vaccine (ARV) for a lower price and saved approximately Rs. 100 million last year.

“Bulk buying, transparent bidding protocols and lengthy negotiations help us provide quality medicines free of cost,” he added.

In 2007, the organization started as a special Sindh Government and Sindh Rural Support Organization Public-Private Partnership Project. Since January 2014, PPHI has been working as an independent company. In these seven years, its legal structure and sphere of activities evolved differently from similar initiatives in other provinces.

Speaking about PPHI’s challenges, Dr Chandio expressed concern over bureaucratic transfer-posting bottlenecks and delays in issuing legal show cause notices.

Although PPHI hires most of its staff on special performance based contracts, the few government employees reporting to PPHI manage to pull transfers, postings, ‘visa’ derailments and unexplained long leaves.

For instance, on the day in question, PPHI received a list of 183 missing staff in Jamshoro, costing PPHI, and eventually, the Sindh Government, a whopping Rs 1.83 million.

To assess PPHI’s claims, we made unannounced trips to PPHI units and comparable or superior government-managed facilities. These units were mainly located in the katcho areas of Sindh’s northern districts. Our findings provide grounds for cautious optimism.

Nara Desert: Footprints on Shifting Sand

PPHI’s Basic Health Unit (BHU) is perhaps the sturdiest structure in Nara town. Built with the assistance of the region’s oil and gas company OMV Pakistan, this health facility boasts around the clock medical services.

Patients expressed satisfaction with the services they received. Laal Mai, whose child was ill, was especially pleased with the unit’s diagnostic testing facilities.

“Without an X-ray, we could not have known about my child’s kidney stones,” she explained. “It also helps to have access to a female doctor. I’m more comfortable discussing my family’s health with her,” she added.

Rural Health Centre, Nara

It had neither electricity nor potable water. Broken beds lay heaped in a disused general ward. Vaccines, diagnostic facilities, bathrooms and functional operation theatres were noticeably absent.

As we sat on broken chairs with fading USAID stickers, the medical officer Dr Shah Muhammad Bhatti elaborated, “I am the only doctor here. The other medical doctor is on leave. Specialist doctors – the paediatrician, gynaecologist, dentist and others posted here – draw salaries but do not report. We have neither electricity nor potable water.”

When asked about the hospital’s ability to provide secondary healthcare services, the doctor chuckled and replied, “If you are injured in a road traffic accident on the damaged road connecting Nara with Khairpur, tough luck. We can only provide basic wound dressing services. Beyond that, we have to refer cases to Khairpur’s Civil Hospital. Blood lost during the three hours drive may limit a patient’s survival chances. The same goes for women in labour. If they need a caesarian section, then they must drive to Khairpur city and risk death on the way.”

Dr Bhatti explained that although aid organisations, corporations and politicians helped with positive interventions, in the absence of rigorous checks such well-intentioned measures remained insufficient.

The broken USAID chairs illustrated as much.

Kot Diji: Fissures in the Fortress – The Weakness Within

Kot Diji Rural Health Centre

Behind the immaculate walls of Kot Diji’s fort, the local population fight to stay in good health. Like Nara’s Taluka Hospital, Kot Diji’s Taluka’s Hospital was disappointing, to say the least.

The absence of electricity, potable water, doctors, nurses, paramedical staff, operation theatre facilities and diagnostic laboratories suggested minimal functionality.

As before, we received disturbing reports of doctors who were drawing pay without working at the facility. Locals explained the visa-derailment system in detail, listing officials with lined pockets and oiled palms.

Basic primary healthcare’s position was remarkably different. Patients queued outside the doctors’ office in PPHI’s BHU. Paramedical staff and the Female Medical Officer (FMO) tended to a patient entering labour.

Women waiting for the lady doctor expressed their satisfaction with the facility. For them, arduous, hard to afford journeys to Khairpur city for pregnancy check-ups were now a thing of the past.

Javed Abro, PPHI’s Sukkur District Manager, observed that, “The numbers speak for themselves. Locals increasingly opt for allopathic healthcare and have greater confidence in the state’s basic healthcare services. I consider that PPHI’s biggest silent achievement.”

Shikarpur: Rewind, Repeat… and improve

Patients at PPHI Jahan Khan, BHU Shikarpur

Spanning Sindhu’s riverbed, Shikarpur’s Lakhi Taluka is home to complex clan conflicts. Although the area’s safety woes persist, its primary healthcare needs are being catered to.

Between 2011 and now, the Jahan Khan BHU has expanded its infrastructure. The centre now spreads over two buildings, providing access to a diagnostic laboratory, well-stocked dispensary, female doctors and paramedical staff. Locals at the unit praised the presence of doctors, medicines, potable water and sanitation facilities.

Sadly, all was not quite as well at the government managed health facility in nearby Mitthal Jatoi goth.

Locked health facility at Mithal Jatao Goth, Shikarpur

Our team found the facility locked. The caretaker, a dispenser, opened the facility to reveal a motorbike and beds bearing signs of residential use.

Discarded cartons of medicines, broken furniture and a few inches of dust graced two rooms open to view. Doctors, patients, electricity and sanitation facilities were conspicuous by their absence.

The caretaker proudly informed us that the facility was operational, thank-you-very-much.

Madrasa, Mithal Jatoi Goth, Shikarpur

The school building facing the health facility and adjacent to the local masjid was hard to miss. But instead of students and school supplies, charpoys and motorbikes dotted the compound, with all the predictable signs of the property being occupied for other reasons.

By way of an explanation, the local maulvi said, “Ustaad natho achey – the teacher doesn’t come to teach.”

Unsurprisingly, in what is now becoming a trend across rural Sindh, local school-age children were going to the ‘pardesi madraso – foreign or non-Sindhi madrasa’ next to the masjid.

When he was asked for details, the maulvi sahib euphemistically replied, ‘Karachi wari Jamiat jo madraso ahey – Karachi Jamiat’s seminary.”

Enough said.

Kashmore: Life on the Peripheries

Connecting the provinces of Sindh, Punjab and Balochistan, Kashmore is a boundary district that lies near the heart of Pakistan’s current oil and gas belt.

The Guddu barrage, oil fields and vast tracts of kacho fall within its boundaries. But despite the district’s strategic geopolitics, or perhaps because of it, residents’ lives are like the state itself: peripheral, existing on the fading edge of the administrative view from Karachi and Islamabad.

Following the pattern of BHUs in other districts, Kashmore’s PPHI BHU was operational. Patients came and went, electricity generators whirred, microscopes and ultrasounds were plugged in. But in contrast with facilities in other districts, this building’s structure suffered from water damage.

It was all too obvious that this area had faced Tori Bundh breach’s floodwaters not too long ago. Considering its location and the physical infrastructure’s shortcomings, this facility’s operational status was no small feat.

Other news from Kashmore remained bleak.

Dr Rukhsana Baloch, a PPHI employee and gynecology diploma holder claimed that there was no gynecologist in Kashmore, not even at private clinics: “Women in need of C-sections travel to Rahim Yar Khan in Punjab or Larkana in Sindh. They frequently suffer irreversible complications on the way.”

The nearby government controlled health facility was closed, and again, under not very legal occupation.

Jacobabad: Disease dogs Pakistan’s Thermal Pole

On 5th December 1848, Brigadier-General John Jacob died of ill health in Jacobabad, the town he helped found. Judging by the state of its secondary healthcare facilities, the district appears to have retained its tragic reputation. Health – or at least superior health service delivery – remains somewhat elusive.

Dog bite victim, Jacobabad Rural Health Centre

With crumbling walls, a falling ceiling, broken beds, inaccessible toilets, absentee staff, and neither electricity nor running water, Garhi Khairo Taluka’s large Qadirpur Rural Health Center (RHC) stood collapsing under years of neglect or malpractice, or both.

Dr Ghulam Murtaza Soomro, the only doctor on duty did not comment on the dilapidated state or his absent colleagues.

A family of four huddled near the facility’s entrance. A boy with angry, blood-shot eyes approached, claiming that the doctor asked for a payment to dress his younger brother’s wound.

“This is a sarkari (public) facility. Why should we pay the doctor a bribe?” he asked.

Vehemently denying the allegation, the doctor offered to dress the wound. Before leaving, as a second thought, I thought of asking how the boy got hurt. “Dog bite,” replied his father.

Panic, and accompanying how-long-agos followed. If a dog bite victim fails to receive a shot of Anti Rabies Vaccine (ARV) within 48 hours, he risks brain damage and near certain death.

Despite the area’s rabies incidence, the RHC, Jacobabad’s civil hospital and private healthcare facilities did not have ARV stocks.

Luckily for the patient, a few phone calls revealed that PPHI’s Jacobabad office would offer him a free ARV shot.

Ward, ambulance and medicine facilities at PPHI BHU Jacobabad.

More worryingly, Dr Chandio explained that providing such vaccines does not fall within PPHI’s activity domain as immunization remains solely under government control.

Exploring maternal and child health issues showed that Jacobabad’s central Maternal and Child Healthcare Center (MCHC) was largely disused. Our source, a local health official, claimed that their MCHC lacked the most basic medicines.

“When I visited, they did not have Paracetamol,” he said. He alleged that the gynecologist’s vested interests made her divert most patients to her own private clinic.

Locals also pointed to a half arranged pile of bricks near PPHI’s Sheeranpur BHU. It was purportedly sanctioned and operating as a Maternal and Child Health Center (MCH). These claims could not be verified further.

By way of more positive news, the nearby BHU was operating well. A fully equipped ambulance stood in the driveway, patients waited in the corridors, and a trained midwife carefully explained family planning and contraceptive options to a couple.

When interviewed, PPHI’s Dr Inayatullah said that monthly community health sessions and health talks in government schools featured among his organisation’s main achievements: “Healthcare cannot be preventative in any meaningful sense till we communicate and spread awareness.”

Kamber-Shahdadkot: Irony Cometh

Medicines at PPHI Basic Health Unit Kamber Shahdadkot

Also a border district, Kamber-Shahdadkot hosts substantial tracts of kacho and roads that frequently drown under floodwater. Its PPHI BHU showed some signs of water damage, but, for the most part, it seemed to be in satisfactory working order.

Patients expressed their contentment with the facility. By way of improvements, they suggested upgrading the facility to a 24-hour one.

When compared with the physical infrastructure of other districts, Kamber’s Wagarh RHC performed relatively better. United Nations Population Fund (UNFPA) and Pakistan National Forum on Women’s Health’s (PNFWH) public health service message on fistula covered the front façade.

A dog at the Rural Health Centre, Kamber Shahdadkot along with Anti-Rabbies vaccine for dog bites displaying a sad paradox.

Inside, vaccines, surprisingly including ARV stocks, were stored in a functioning refrigerator – a definite first when compared with other districts. Sadly, the 24 hour facility had neither patients nor doctors.

According to the note in the medical officer’s office, the doctor was away on polio training. His named replacement doctor was neither present nor expected at the facility.

A stray dog blocked the entrance to the empty labour room.

“In case that dog bites someone on this facility, we have ARV stocks,” the local health technician wryly observed.

Tragic irony, thy name is Pakistan.

In Toto Perspective: Half-full, Half-Empty or Neither? Your Call

The successes on the basic primary healthcare front are undeniable.

Through interventions such as PPHI, Sindh’s people now have better access to good quality basic medical services. Female doctors who were previously unavailable at many BHUs are now serving in otherwise hard to reach villages.

Newly available diagnostic facilities enable doctors to accurately detect and treat anemia, tuberculosis, hepatitis, dengue, malaria, pregnancy complications etc. And with PPHI's recently started ambulance service, local populations can now access emergency medical services with greater ease.

PPHI’s savings have paved the way for several new interventions. The most promising of these is the recently started ice-liner program. Load-shedding induced inability to maintain the cold-chain tends to reduce the potency of vaccines.

“UNICEF donated ice-liners to solve this problem. Sadly, those ice-liners were proving to be inadequate for Sindh’s immunization needs,” Dr Chandio claimed. PPHI’s small intervention in a few southern Sindh districts on this head carries the promise of improving the province’s immunization coverage.

That acknowledged, the situation is far from perfect.

Several challenges remain, both within PPHI and between PPHI and other health programs. Sindh’s current health sector complex contains a whole host of vertical healthcare programs with little or no coordination mechanisms.

Several activities, especially those related to vaccination and nutrition are overlapping, and in some places, involve considerable resource doubling.

Monitoring remains inadequate. Names and details of absent staff are available to all stakeholders but no punitive legal action follows. In the resulting apathetic chaos, the euphemistic ‘transfer-postings’ or ‘visa system’ makes white what appears otherwise appears black.

Answering the 'why' behind the current state of affairs is about as complex as it is futile.

Take the example of the pile of bricks that locals alleged was Jacobabad’s Maternal and Child Healthcare Center (MCHC). Assuming that local claims are true, no one comes out looking entirely blame free: the locals thought that the centre was operational on paper but they didn’t pressure the district’s health administration to make it practically functional. Absentee staffers were community members.

The local administration wasn’t merely passively ignoring the situation. Allegedly, it was actively involved in taking bribes from absent staffers and getting cuts from their private clinics.

To top it all off, Karachi and Islamabad’s health authorities did what they always do: express a mix of ignorance, resignation and pitiful helplessness.

In sum, that pile of bricks is a metaphor for the challenge facing Pakistan today.

Considering the scale of these things, the who-done-it question gets us to this: the village, the society, the state ‘done it.’ And we’ve ‘done-it’ for over 66 years.

The more useful question then, is this: How do we fix all this? If the PPHI model shows one thing, it is this: Can Do.

Scrap the pessimism and see the light of each day’s new dawn. With some monitoring, automated attendance checks, limits on transfers-postings, merit-based appointments and legal notices checking administrative malpractice (read: bhatta), Sindh’s basic health units have now risen from their past comatose state.

The same result is entirely possible for secondary and tertiary healthcare centers. That said, wholesale contracting out, or more worryingly, privatization, would set a bad precedent.

Constitutional decency requires that the state comply with its basic service delivery duties. Instead of exporting responsibility from its current stock of employees, our executive could try implementing transparent, exacting, technology-friendly monitoring and reporting requirements. Stricter accountability standards would hardly hurt.

To return to where we started, a decade ago, Shikarpur’s basic health facility was closed.

Two years ago, it was operating.

Last month, it was expanding.

Even as challenges persist in the clumsy chaos that is our public sector, some degree of transparent monitoring, reporting, auditing and management can, and will, change things around for the better.