Arif Azad’s ‘Patient Pakistan: Reforming and Fixing Health Care for all in the 21st Century’ is an excellent collection of essays written over the past few years for leading Pakistani English newspapers, especially Dawn. Some of them were written up to eight years ago and were clearly inspired by significant ongoing events such as a disease outbreak, unexpected multiple deaths due to an unsafe drug on the market, or a failure of hospital management – yet they remain remarkably relevant to Pakistan’s healthcare sector today. Arif Azad uses a broad structural lens to understand and explain localised events and failures of the healthcare system. Unfortunately, the structural conditions that have plagued Pakistan’s health system for decades – which have turned the country into ‘patient Pakistan’, according to Arif Azad’s well-chosen title for the book – have not changed for the better. As a result, most of Pakistan’s health indicators continue to be dismal, regardless of the country’s commitment to the Millennium Development Goals (MDGs) and other such international commitments. In this sense, this book offers a timely analysis of the healthcare sector in Pakistan. It demonstrates a comprehensive knowledge of the local health landscape and presents a credible and well-written analysis of how this landscape sits with global health discourses and practice.
The essays in the book are grouped into eleven sections reflecting some of the key themes in Pakistan’s health system, canvassing health-related policies, processes and practices, the burden of communicable and non-communicable diseases, sexual health and public morality, drug-pricing and regulation, the role of NGOs in health service delivery, and hunger, malnutrition and safety nets for the vulnerable. All of these topics are of great relevance to understanding and improving Pakistan’s battered health system, as indicated by recent controversies over the privatization of major government hospitals in cities like Karachi and Lahore, or the federal government taking over the management of these hospitals; the recent deaths of several new-born infants due to faulty air-conditioning and negligence at a government hospital in Sahiwal; recent HIV outbreaks in Sindh and Punjab which have led to a crackdown on ‘quacks’ or untrained medical practitioners; setbacks in the End Polio campaign due to public controversy over the quality of vaccine; an alarming hike in drug prices and calls for their better regulation; and high-level policy statements by the prime minister on the very high rates of stunting and wasting among children in Pakistan, which are amongst the highest in the world. Thus the problems highlighted in the book are recurring and current. The significance of the book lies in not only explaining these problems to a lay readership in an accessible way, but also suggesting viable solutions and thus contributing to a public discourse on improving the health of ‘patient Pakistan’.
Arif Azad’s approach to explaining a complex set of factors and their entanglements is very effective. He begins each of his articles with a broad canvas, situating a given problem within broader global health discourses and Pakistan’s policy commitments and legal obligations around it. He then describes in some detail significant aspects of the problem in its local setting before moving on to explaining it within broader structures of policy and politics in the country. In each case, this is then followed by very clearly delineated and often convincing recommendations for fixing these problems, sometimes stated even in the form of bullet points. One criticism of the book is that the analysis sometimes verges on the optimism of the magic bullet/technical fix approach, which is problematic from a social scientific viewpoint. For example, suggesting that breastfeeding promotion is the ‘silver bullet’ for dealing with the problem of early years malnutrition is great, and may find a lot of currency with policy-makers, but the devil is in the details. How do you make sense of the low uptake of such educational initiatives, and what can be done about that? Arif Azad’s own broader frame of structural analysis would have been helpful in answering these questions, but his recommendations sometimes appear to belie the complexity of his framework.
Arif Azad draws on the extensive first-hand knowledge of health systems across the world which he gained over an illustrious career as a public health expert for international NGOs such as Médicins Sans Frontières, the Network for Consumer Protection, DFID, UNDP and USAID. In addition to being a prolific writer and public health expert, Arif Azad is also trained as medical doctor, which must add to his insights on problems of health and illness. Importantly, however, his approach in the book is not bound by narrow disciplinary confines. He weaves in very convincing accounts by drawing on his knowledge of economy, society, geography and environment, and it is this multidisciplinary complexity which makes his arguments holistic and valuable. This book is highly recommended for not only students, practitioners and policy-makers in the healthcare field but also members of the interested public.