Series

Health Transitions in Pakistan 4 Health reform in Pakistan: a call to action

Sania Nishtar*, Zulfi qar A Bhutta*, Tazeen H Jafar, Abdul Ghaff ar, Tasleem Akhtar, Kaiser Bengali, Qazi Asmat Isa, Ejaz Rahim

Pakistan’s enormous macroeconomic, internal, and human security challenges coexist alongside the opportunity Lancet 2013; 381: 2291–97 created by a huge desire for change. With democracy taking root and a new constitutionally ushered era in state Published Online governance, The Lancet Series about Pakistan and health focuses on health as a nation-building and social-welfare May 17, 2013 agenda at a time of unprecedented social upheaval and economic hardships in the country. We call for a unifi ed vision http://dx.doi.org/10.1016/ S0140-6736(13)60813-2 for the goal of universal and equitable health access. We provide recommendations for six objectives for policy and This is the fourth in a Series of action. Higher political priority for health, increased investments, a combination of targeted and universal approaches, four papers about health action in terms of the social determinants, institutionalisation of the right organisational network, and frameworks transitions in Pakistan for accountability are crucial for the attainment of the health goals in Pakistan. *Joint fi rst authors Heartfi le, Islamabad, Pakistan Introduction cover fi nancial support and the achievement of equity for (S Nishtar PhD); Government of Pakistan is a kaleidoscope of hope and despair, and the country’s diverse population in terms of sex, ethnic Pakistan, Islamabad, Pakistan obscurantism stymying progress, frequently manifest origin, and socioeconomic classes. We recommend six (S Nishtar); Division of Women and Child Health, Aga Khan in the courageous faces of young people who want objectives for policy and action that the federation and University, Karachi, Pakistan change. Despite a history with several periods of military the provinces should focus on over the next decade. (Prof Z A Bhutta PhD, dictatorships, the previous parliament was the fi rst ever Prof T H Jafar MPH); Alliance for Health Policy and Systems elected to complete its tenure; elections are scheduled Political ownership of health Research , Geneva, Switzerland in May, 2013. Pakistan still has complex challenges. The Health has never been a political priority in Pakistan, as (A Ghaff ar PhD); Peshawar, wars along Pakistan’s northern borders, regional evident from the persistently low fi scal support. Party Pakistan (T Akhtar FRCP); instability, problems with internal security, economic manifestos generally do not present specifi c fi scal solu- Karachi, Pakistan (K Bengali PhD); Pakistan decline, and persistent energy defi cits, have taken a tions that can enhance investments in health; table 1 Poverty Alleviation Fund, huge toll on the country and its population. Weak summarises the key features of political party manifestos Islamabad, Pakistan governance, uncon trolled population growth, and that were made public before April 15, 2013. Some of the (Q A Isa PhD); and Islamabad, natural disasters have also aff ected all dimen sions of political parties have explicitly outlined their plans for the Pakistan (E Rahim MA) health and human development. health sector in manifestos for the forthcoming election. Correspondence to: Yet, the Pakistani society is remarkably resilient and However, with few exceptions, there has been no robust Dr Sania Nishtar, Heartfi le, 1 Park Road, Chak Shahzad, there are developments that bode well for the future. public debate about the issues and possible solutions. Islamabad 44000, Pakistan Pakistan’s demographic resources remain untapped. Various initiatives, which had the potential to reform sania@heartfi le.org The advent of judicial activism and its foray into human health, were hampered by policy vacillations and several or rights issues and public policy have led to the realisation changes in government (panel). The time is now right to Prof Zulfi qar A Bhutta, Centre of of the right to health. A free and open media, and have a consensus about key issues including health and Excellence in Women and Child support for democracy have created opportunities for education and move forward. We call on political stake- Health, Aga Khan University, Stadium Road, Karachi 74 800, public debate and social change. Despite its hasty imple- holders to convene an all-parties conference on health to Pakistan mentation, the 18th Constitutional Amendment to achieve consensus for needed actions with multi stake- zulfi [email protected] devolve education, health, and substantial resources to holder ownership and oversight of the process. Importantly, the provinces has created an opportunity to reform commitment is needed on an agreed set of actions. governance and improve accountability in many sectors including health.1 Increased overall public spending on health In a rapidly changing environment, rarely have the The public sector spends 0·9% of Pakistan’s gross Pakistani people had the luxury to take stock and generate domestic product (GDP) on health—low by any stan- the political and public support to address the closely dard.2 The health indicators are also poor, with rates of intertwined issues of health, human security, and infant and maternal mortalities much higher than develop ment. The Lancet Series about Pakistan and the goals set by the Millennium Development Goals health provides an opportunity to undertake an analysis (MDGs),3 and high rates of non-communicable diseases of the past and present and off er options for the future. in young adults leading to loss of national productivity.4 In this call to action, our aim is to build on the other Public investments by the federation and provinces reports in this Series2–9 to help renew Pakistan’s com- should increase to at least 5% of GDP by 2025 as mitment to health, with the focus on equitable and committed by some political parties. Even in the universal health access as the goal. Because of the huge existing constrained setting, spending on health could challenges resulting from the diff erentials and inequities be increased if resources are managed better. For in Pakistan, the focus on universal health access should example, despite obvious solutions to free up these www.thelancet.com Vol 381 June 29, 2013 2291 Series

Key messages

• At a tumultuous time in Pakistan’s history, the synergy • Creation of a federal health information hub linked between the forthcoming 2013 parliamentary elections and to the health division. societal demand for change can help to put health on the • Transparent governance and adequate resourcing of nation-building agenda. regulatory, research, and capacity building institutions. • In addition to being a future vision, equitable, universal • Policy for human resources in health that complies health access can be the much needed indicator of domestic with the 18th Constitutional Amendment (agenda policy and goal for Pakistan’s health system. shared by the federation and provinces). • Devolution of health to the provinces by the 18th • Steps needed at the provincial level outside the Constitutional Amendment off ers unique opportunities for health sector: action and accountability, but requires sound planning, • Accountability and performance-promoting culture resourcing, organisational reform, and oversight at federal in the local government. and provincial levels. • Earmarking of a service tax for welfare and health (to • Many institutional arrangements are still in fl ux while a increase money for health). democratic transition is underway. The disarray of the local • Establishment of compulsory health insurance government system adds another level of complexity. In this schemes for formally employed individuals (to setting, we propose an institutional and organisational increase money for health). framework for health. Additionally, the following steps are • Improvements in fi nancial access to health equity deemed necessary to reform health over the next funds for individuals who are poor (to increase parliamentary term. money for health). • Steps needed at the federal level outside the health sector: • Innovations in the existing social protection • Overcoming Pakistan’s fi nancing emergency (to programmes to risk protect the poorest individuals increase money for health). from health shocks (to increase money for health). • Stakeholders’ consensus on a direction for the health • Investment in public health diagnostic capabilities. sector through an all-parties conference. • Steps needed at the provincial level in the health sector: • Interprovincial equity-promoting innovations in • Provincial policies for strategies to achieve universal the National Finance Commission Award (to health access. increase money for health). • Adequate and sustainable support for provincial health • Adequate resourcing and autonomy of health reform and policy units, and public health schools. institutions. • Policy for human resources in health that complies • Increase in excise duty on cheaply sold cigarettes with the 18th Constitutional Amendment (agenda and channelling of revenue towards initiatives for shared by the federation and provinces). prevention of non-communicable diseases (to • Improved resourcing and management of public increase money for health). service delivery facilities. • Introduction of nutrition and maternal, newborn, • Introduction of programmes for population and child health in the national income support planning, non-communicable diseases, and programme. integration of communicable disease control into • Steps needed at the federal level in the health sector: primary health care. • A national health policy that conforms with the • Incorporation of population-wide high blood pressure mandate in the 18th Constitutional Amendment. screening in the work plan for lady health workers. • Establishment of a health division under the Ministry • Targeted links with the private sector for specifi c of Inter-Provincial Coordination. objectives, such as emergency transport systems. • Reorganisation of the reporting relations of agencies. • Capacity building to harness private sector outreach.

resources, a signifi cant proportion of the budget is ventions. Pakistan has the lowest tax-to-GDP ratio among invested in failing public sector enterprises. The direct the developing countries; therefore, the widening of the and indirect admin istrative costs for offi ce bearers and tax net is imperative. The provincial mandate to levy a government departments are huge, and promotion of service tax can additionally be used for generating austerity would increase resources for health. resources for health and development. Health is one of the most corrupt sectors in Pakistan; After the 18th Constitutional Amendment, the federal therefore, plugging corruption-related leaks could have a government has the role of bridging inequities between huge benefi t for health funding. Provinces now have federating units. The National Finance Commission additional recognition for fi scal support under the Award for innovations in Pakistan’s traditional fi scal National Finance Commission, but the money needs to formula, which determines provincial allocations by the be allocated equitably for universal and targeted inter- federal government, can enable the federation to

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expedite provincial invest ments in priority social quickly to address fi nancial barriers to seeking health sectors. External development assistance, most of which care. The existing income support programme can be is now given to provinces, should not displace domestic leveraged for nutrition and maternal, newborn, and child funding, as in the past. health (MNCH) and innovations in social protection can Earmarking of revenue for health should be simul- help safeguard the poorest individuals from health For the Pakistan Tehreek-e- taneous with policy approaches to increase pooling at the shocks.23 Targeted links with the private sector can Insaf’s policies see http://insaf. provincial level. Establishment of a compulsory health improve specifi c service dimensions—eg, emergency pk/Policies/Health/tabid/318/ Default.aspx insurance scheme for formally employed individuals and transport systems, which are largely in the private sector. For the Pakistan Muslim improving access to health equity funds for people who Similarly, links with the non-profi t sector can enable League-Nawaz manifesto see are poor and those in the informal sector have been targeted nutrition interventions in schools, as tested in http://www.pmln.org/pmln- explained elsewhere in this Series.2 the past. Additionally, targeted approaches can be adopted manifesto-englishurdu/ in outreach programmes. The quality and outreach of For the Pakistan People’s Party Universal and targeted health access lady health workers can be improved by optimisation of manifestos see http://www.ppp. Provinces should accept universal health access as an their role and integration of key interventions relevant to org.pk/pppchange/manifestos. html overall indicator of domestic policy. Action to expedite their role in primary care and family planning, and For the Mutahida Quami progress in terms of the MDGs and reduction in the provision of services such as screening and prevention of Movement see http://www. burden of major non-communicable diseases, the likely non-communicable diseases. For too long, this cadre of election2013.pk/election/ health sector goals after 2015 (the current MDGs will come community health workers has borne the brunt of detail/27 to term by the end of 2015), should be the focus of the primary care in rural populations with few links with the For the Jamaat-e-Islami programme for universal health access (table 2). formal health sector in the districts. Now we need to manifesto see http://www. forum.jamaat.org/forum/jamaat- A three-stage approach is recommended. First, services strengthen the quality and distribution of trained mid- e-islami-pakistan/elections- that can enable targeted access can be employed fairly level workers and physicians in districts. 2013/208-electoral-manisfesto

Pakistan Tehreek-e-Insaf Pakistan Muslim League- Pakistan People’s Party Mutahida Quami Jamaat-e-Islami Nawaz Movement Overall vision for Health as an emergency National Health services across Health for all Health for all ·· health and key Pakistan policy Health expenditure 2·6% of GDP 2% of GDP 5% of the consolidated 4% of GDP Increase committed, increase by 2018 government spending percentage not specifi ed Measures to Not specifi ed Not specifi ed Not specifi ed Not specifi ed Not specifi ed increase money for health Other quantifi able 100% improvement in the existing public 100% vaccination of children; Reduction in population growth ·· ·· goals and targets sector coverage 50% reduction of maternal and rate from 2% to 1·6%; during term infant mortality rates; 10% poliomyelitis eradication by 2015 reduction in population growth; and 100 mobile health units Approach to health Health equity fund emulating a model by a National insurance scheme Waseela-e-Sehat, a health Health insurance for all Islamic insurance fi nancing non-governmental organisation; support for funded and managed by insurance scheme for individuals individuals, with elderly (takaful) private sectors in insurance; a social security provincial governments identifi ed by a nationwide poverty people being a priority opt-out option for private employers survey as being poor Health governance Federal health division; district health District health authority with an Strengthening provincial ·· ·· boards; elected village councils; hospital autonomous board; hospital ministries of health; focus on autonomy policy autonomy policy transparency in resource use Service delivery Dentists in all rural health centres; upgrading Strengthening basic health units Upgrading of subdistrict and ·· Free emergency of accident and emergency in these centres through private sector district hospitals; mobile preventive treatment and free near major roads; investments in partnerships; mobile health teams; focus on communicable treatment of outpatients management information systems; units; and effi cient medicolegal diseases and programmes for lady in evenings in public partnerships with private sector; focus on services health workers, maternal, neonatal, hospitals communicable and non-communicable and child health, and Expanded diseases, maternal, neonate, and child heath, Programme on Immunization and school health Human resources Health management, and paramedics ·· Paramedics; degree course in ·· ·· for health nursing Medicines Food and drug testing laboratories; support Tighter price regulation; curbing Scaling down list of essential ·· Generic medicines policy for the Drug Regulatory Authority spurious medicines; support for medicines list; tighter price and tax-exempt the Drug Regulatory Authority control; support for Drug imported medicines Regulatory Authority

GDP=gross domestic product.

Table 1: Key features of specifi c health-related commitments in 2013 manifestos for some of the main political parties

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Second, public sector health infrastructure should be and the merger of family planning with primary health improved because it would enhance universal access. care to bridge the existing gap in population health. Improvement in the infrastructure can be enabled by Third, methods for private sector engagement and the reform of primary health care and hospitals.2 An service purchasing should be identifi ed. Provincial agenda for integration is crucial for the reform of governments should enhance their capacities to engage primary health care. Reform could be achieved through with the private sector before embarking on programmes the integration of existing vertical communicable for achieving universal health care as their contribution disease programmes into one programme after their to aff ordable quality health care is crucial. devolution from the federal to the provincial govern- ments, and the incorporation of pro grammes for non- Health organisations and policy communicable diseases into primary care programmes, The 18th Constitutional Amendment man dates federal, national, and interprovincial functions or roles in health in Panel: Examples of programmes in Pakistan that have legislative lists; the other mandates are for provincial been hampered by policy vacillations functions. Institutions exist at the federal level to serve the mandated functions, but they have not been meeting these • Tawana Pakistan Project10 functions since the abolition of Pakistan’s Ministry of • Women’s Health Project11 Health after the 18th Constitutional Amendment. Without • Family Health Project12 detracting from the devolution of health to the provinces, • Social Action Programme13 we recommend the creation of a federal institutional • National Action Plan for Prevention and Control of system to support the provincial departments of health. Non-Communicable Diseases in Pakistan14,15 Creation of a central coordinating structure for health is • District Health Authorities Initiative16 necessary because many of the problems arising soon after • District Health Government Initiative16 the 18th Constitutional Amendment were a manifestation • People’s Primary Health Care Initiative17 of the absence of this structure.24 The focus at the federal • Access to Justice Project18 level should be on coordination, technical support, and • National Commission for Government Reforms19 discharging of responsibility for federal roles rather than • Automation of the Central Board of Revenue20 exercising bureaucratic and fi nancial controls over • Improvement to Financial Reporting and Auditing Project21 provinces, which was the case before the 18th Constitutional • Tax Administration Reform Program22 Amendment when the Ministry of Health was re sponsible for provincial health.25 A national policy commensurate with federal functions needs to be established so that it Existing institutional responsibility at the federal level enables the development of a unifi ed national vision for Legislative list, part 1 (federal subjects only) health in view of the federal government’s interprovincial Health insurance (unless Responsibility not specifi ed equity promoting role. undertaken by the province) We propose the creation of a health division in the Professional or technical Pakistan Medical Research Council and the Health Services Academy have training; research (shared been retained at the federal level and report to the Cabinet Division federal government to link with appropriate ministries mandate) and special studies and divisions for the requisite provincial convening and Federal public services Responsibility of the Federal Public Services Commission and Capital coordination and global interaction (fi gure). The health Administration and Development Division division could also serve as the point of coordination Education of foreign students Responsibility of the Economic Aff airs Division with other federal level divisions and ministries, which Health information and Institutions responsible report to diff erent federal agencies—National have the health mandate. disease security Regulations and Services Division; Cabinet Division; States and Frontier Region Provinces, which now have the main responsibility for Division; Federal Bureau of Statistics; Planning and Development Division Some have been devolved to provinces personalised medical care and public health, should Currently, health information is fragmented2 develop sustainable institutions with the capacity to plan Trade in health Pakistan’s trade policy does not factor in trade of services in health and oversee reform. International experience shows that Trademarks and patents Dealt with through the Registrar of Trademark’s Offi ce the success of reform is determined by appropriate in- Regulation of drugs and The major provinces (Baluchistan, Khyber Pakhtunkhwa, Punjab, and Sindh) country technical capability.26 After the 18th Constitutional medicines have conferred this mandate to the federal Drug Regulatory Authority, Amendment, provinces have three units with overlapping which reports to the National Regulations and Services Division roles—secretariat, directorate, and provincial health Legislative list, part 2 reform. Importantly, duplication should be avoided and Regulation All regulatory institutions report to the National Regulations and policy making should be separated from regulation, Services Division oversight, and analysis. Also, in view of the scale down of Medical profession Human resource regulatory agencies report to the National Regulations and Services Division the local government system, safeguards should be National planning and Economic Aff airs Division, Planning and Development Division, and developed against recentralisation of power, an adverse economic coordination Ministry of Inter-Provincial Coordination deal with diff erent aspects outcome of the amendment. Other key gaps at the institutional level are the absence Table 2: Health-relevant subjects enumerated in the 18th Constitutional Amendment’s legislative lists of programmes for non-communicable diseases at

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Ministry of Finance Ministry of Inter-Provincial National Regulations Coordination and Services Ministry

Statistics Division Planning and Health Division College of Physicians and Surgeons Development Division Drug Regulation Authority National Council of Homoeopathy Pakistan Medical and Dental Council Health information Pakistan Nursing Council cell in Health Division Pharmacy Council of Pakistan

Federal Bureau of Statistics Academic institutions, • Directorate of Central Ministry of think tanks, and Health Establishment Economic Affairs agencies outside the • District health health sector (such information system • National Health as National Institute • Disease early Accounts Economic Affairs of Population Studies warning system • Pakistan Demographic Division and Pakistan Institute • Epidemic investigation Survey of Development cell • Other representative Economics) • Field Epidemiology surveys—eg, demographic and Laboratory and health surveys, Training Programme multiple indicators • Integrated disease cluster surveys, social surveillance and and living standards response surveys, and national Links with other agencies nutrition surveys Direct reporting Collaborative arrangement

Figure: Suggested framework for the federal health sector after Pakistan’s 18th Constitutional Amendment provincial and federal levels, weaknesses in public health Importantly, the social determinants of health need to diagnostic capabilities, poorly functioning regulatory be addressed. Per person income has a strong correlation arrangements for medicines, human resources and with the achievement of health status and therefore levels medical education; and the fragmentation of health of employment, poverty reduction, and pro-poor inclusive information-related institutions and the persistent health– growth matter are crucial for health gains. Some population disconnect after the 18th Constitional recommended tar geted approaches, including integration Amendment. Additionally, some institutions for research, of nutrition and MNHC, are predicated to have the training, and reform are deeply politicised and have potential for poverty alleviation. Maternal education, and inadequate resources; these issues need to be addressed. adequate nutrition, clean water, and sanitation can have The creation of a national public health network of profound eff ects on health status, and emphasise the institutions and professionals is an essential step in the need for action to streamline the local governments.3,28 eff ective planning for health reform in Pakistan. Planned action to address the social determinants can be a waste of time without attention to population planning.5 Social determinants and intersectoral action Pakistan has to invest in direct and indirect strategies to Actions outside the health sector can aff ect health reduce its population growth.29–31 outcomes and performance of health systems. Pakistan Much of the scope of public health work is usually should broaden the focus of its security policy, which is separate from the medical care services. Some of the key national security. An emphasis on human security can recommended actions to address non-com municable be achieved by elaboration of the defi nition of “security diseases and injuries—including, increase in excise duty of a person” in article 9 of the constitution. Health is on cheap cigarettes and number of speed bumps, one of the seven recognised determinants of human respectively—need action from outside the health sector. security. Imperative for Pakistan is the security of its The potential benefi ts of technology can be tapped communities from internal strife, and ethnic and through intersectoral action. In Pakistan, the eff ect of political tensions. More than 30 000 people have died in climate change is now palpable. However, the implications the country as a result of acts of terrorism, including at of climate change for vector breeding, disease patterns, least 85 doctors and sixteen community health workers food security and human health have as yet not been fully involved in the poliomyelitis eradication campaign.27 appreciated in national planning processes. Peace, law, and order are crucial for human security and health system functionality. These are also Accountability necessary to free up money and priorities for human The performance of health systems is dependent on development agendas. overall governance. Accountability is the foundation for www.thelancet.com Vol 381 June 29, 2013 2295 Series

good governance. However, Pakistan’s existing norms do In addition to its national relevance, universal health not require fi nancial, managerial, and decision-making access will resonate with global thinking. The MDGs will accountability. The previous parliament was unable to come to term in 2015. Universal health access is being legislate in terms of accountability during its 5 year term. positioned as the health sector’s key contribution to the This gap in accountability will be a major limitation after achievement of health goals after 2015—expediation of 2015, when country ownership and accountability are the MDGs and reduction of the burden of major non- likely to have more importance. A robust accountability communicable diseases. Also, unlike the MDGs that law and arrangements for implementation are priorities were created for the aid system, the shift in development for health and governance. The Commission on Infor- circles evaluating the post-2015 options is to help shape mation and Accountability provides recommendations national policies with an emphasis on investment rather for the health sector. An independent national structure than aid, and country ownership in terms of resource could be charged with the responsibility for accountability generation and deploy ment to achieve social targets. within the framework of national and international Pakistan is off track in meeting the MDGs and the targets settings in health and could be nested within an for burden of disease. A concerted focus on the appropriate institutional structure—eg, the federal and achievement of equitable universal health care could provincial planning commissions. Pakistan needs to help Pakistan to meet these goals within the next actively consider and adopt its own tangible targets for generation, if not earlier.32 accountability. Crucially, the new parliament must have Pakistan therefore has to pitch the attainment of accountability as a priority. health at the right political and institutional levels. Although health has moved up in the political debate Conclusions relative to previous years, it still needs to move up Despite the many challenges and opportunities, the further. The democratic elections in May, 2013, and the 18th Constitutional Amendment has led to massive parliamentary phase commencing after a change of changes in Pakistan’s governance system by altering government could be a historic landmark in Pakistan’s federal–provincial relations. Many arrangements are still varied history. After decades of confl ict and war on in fl ux while a democratic transition is underway. The various borders, there is an unprecedented desire for disarray of the local government system adds another peace and calls for accountability. Investments in level of complexity. In this setting of unprecedented population health and human development might be social upheaval, economic hardships, and drastic changes the key for true national security and Pakistan’s survival in Pakistan’s institutional and organisational systems, we as a nation state. believe that health should be included in a nation- Contributors building agenda. More broadly, the agenda also includes SN and ZAB conceived the idea for the report and wrote the fi nal a future vision of universal health access and narrowing version. All authors contributed to the review and writing process. SN of inequity as its goals. and ZAB are the guarantors for the report. Economic preconditions for universal health access are Confl icts of interest hugely challenging in view of Pakistan’s fi nancial situation We declare that we have no confl icts of interests. and its current tax-to-GDP ratio and leave little money for Acknowledgments SN and ZAB thank Heartfi le and Aga Khan University, respectively, for much needed reforms in health and social sectors. their support. However, Pakistan seems to be on the cusp of change that References could be leveraged with the initiation of the social political 1 Government of Pakistan. Full text of the 18th Amendment Bill. culture, a democratic dispensation, and a new order of http://www.infopak.gov.pk/Constitution/Full%20text%20of %20 relations in its federating system. With a new parliamentary 18th%20Amendment%20Bill.pdf (accessed March 25, 2013). 2 Nishtar S, Boerma T, Amjad S, et al. Pakistan’s health system: phase commencing in 2013, universal health access can performance and prospects after the 18th Constitutional become part of a broader political movement for social Amendment. Lancet 2013; published online May 17. http://dx.doi. welfare reform at a time of unprecedented social and org/10.1016/S0140-6736(13)60019-7. 3 Bhutta ZA, Hafeez A, Rizvi A, et al. Reproductive, maternal, economic hardships in the country. International experi- newborn, and child health in Pakistan: challenges and ences also show that reform of universal health access is opportunities. Lancet 2013; published online May 17. http://dx.doi. usually brought about by a major change—including, org/10.1016/S0140-6736(12)61999-0. 4 Jafar TH, Haaland BA, Rahman A, et al. Non-communicable diseases political transitions, cataclysmic events, disasters, and and injuries in Pakistan: strategic priorities. Lancet 2013; published solutions to special over-riding problems. Pakistan has online May 17. http://dx.doi.org/10.1016/S0140-6736(13)60646-7. experience of all these. Therefore, the debate about health 5 Sathar ZA. Family planning: a missing priority in the health sector? has to be broadened to include nation-building and social Lancet 2013; published online May 17. http://dx.doi.org/10.1016/ S0140-6736(13)60763-1. welfare, and the widespread desire for change. Such an 6 Ghaff ar A, Zaidi S, Qureshi H, Hafeez A. Medical education and agenda will have resonance with all the sectors involved in research in Pakistan. Lancet 2013; published online May 17. http:// the development of universal health access and help in the dx.doi.org/10.1016/S0140-6736(13)60146-4. 7 Rasmussen B, Allen S, Rasmussen ZA, Bajwa R. Learning from attainment of the broader goals for development, social disasters to save lives every day in Pakistan. Lancet 2013; published protection, and poverty alleviation. online May 17. http://dx.doi.org/10.1016/S0140-6736(13)60652-2.

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