December 13, 2012

Faith Based Health Care Policy in Gilgit Baltistan

There was a time when people used to call Gilgit Baltistan the land of peace, love and happiness, but today a cloud of gloom hangs over the region.

Because of the recent wave of sectarian violence in Gilgit Baltistan, hundreds of people have died and the economy is on the verge of collapse. The education and healthcare sectors are among the worst hit.

As the government and the security agencies find out and address the causes of sectarian violence, there is also a need to revisit our current policies and reevaluate our current system of governance. Decent, acceptable and long-term coping strategies should be devised to address the grave issue of sectarian violence.

We cannot fulfill the dream of a pluralistic society by dividing our healthcare system along sectarian lines

Being a health professional, I believe some of the most important challenges will be in the healthcare sector. The existing healthcare policies and strategies have not been developed professionally and scientifically. These ill-conceived, narrow minded and misguided policies are also essential contributing factors to the sectarian violence in Gilgit Baltistan. In an ideal world, hospitals are constructed to provide the highest quality of care to all people regardless of their faith. Doctors, nurses and other health professionals are committed to helping and assisting everyone everywhere irrespective of their sect, race and color. But the public healthcare resources in Gilgit Baltistan seem to have been divided along sectarian lines.

The District Headquarters Hospital (DHQ) in Gilgit is the oldest public hospital in Gilgit Baltistan and was built in a Shia dominated area more than 50 years ago. It served people from all across the region. People living in the vicinity of the hospital helped the poor patients and attendants coming from far off districts, often giving them food and clothing. Sometimes they also accommodated them in their houses. Shia and Sunni health professionals worked together and provided best possible services to the population despite of the scarce resources.

Today, things are different. Sunni patients are reluctant to visit the DHQ hospital. Even Sunni health professionals have declined to work in the hospital. Instead of pacifying tensions and finding a pragmatic solution to the issue, the government built another hospital in Kashrote, a Sunni dominated area, just three kilometers away. Sunni health professionals have been deployed to this new hospital and it largely serves the Sunni community.

At a distance of a few yards from the Kashrote City Hospital, the Aga Khan Health Services have also set up a well-equipped hospital. The hospital is neither located in an Ismaili dominated area nor meant to serve the Ismaili population only, but some people still assume that a good number of health professionals and majority of patients coming to this health facility are Ismailis.

Is there really a need for so many hospitals in Gilgit city? Are we not wasting our resources? Can't we set up one large well-equipped hospital in Gilgit that can provide quality healthcare to everyone regardless of their faith? Will the sectarian based healthcare approach end violence in Gilgit Baltistan? On the contrary, it might deepen the sectarian rift. We cannot fulfill the dream of a pluralistic society by dividing our healthcare system along sectarian lines.

                                 Published in "The Friday Times" on December 14-20, 2012

November 28, 2012

The Politics of Health in Pakistan

The health of a nation can be measured by its health care system while the health care system hinges on the country’s national health policy and strategy. The country’s political leadership is the principal driving force behind such policies and strategies. If you want to know how strong the country’s political leadership is, look at its key health indicators and you will get a fast answer to your question.

Pakistan is in the list of developing countries where the health care system is still on life support. India has joined the international community in waging a war against global health issues but unfortunately, we are not yet able to control vaccine preventable diseases like polio in our own backyards. It’s a shame that sixty-five years after independence, the total immunization coverage is still at a low level. Diarrhea, pneumonia and malnutrition are still the main causes of deaths among children under five. Hundreds of thousands of pregnant women still die because of severe bleeding, infections and high blood pressure.

The question on everybody’s mind is: isn’t the government doing enough to tackle these problems? The answer is most likely no. Health and education are the most neglected sectors in Pakistan. Look at the state budget of last five years and see what percentage of the federal budget is allocated for health care in the country.

The health sector reforms will never take place until the political leaders and other policy makers understand the problem, express their viewpoints and act accordingly. As a public health professional, I will bring to light some key health issues that I noticed during my professional career in Pakistan.

Human resources for health are identified as one the core building blocks for a health care system. The biggest challenge facing the health care sector is the serious lack of human resources. The model of putting the qualified and right people in the right place has never been used in Pakistan. In order to get a holistic view of a situation,let’s take the health ministry as an example. Country’s public policy making lies in the hands of non-health professionals (like ministers, secretaries etc). You will hardly find qualified health professionals and researchers at relevant health ministries.
Meritocracy does not exist anywhere in the country. Recruitment, transfer and promotion processes are based on several factors such as political affiliation, ethnicity, class, religion, bribes etc. Because of the dismal situation, many qualified health professionals are either leaving the country or joining the private sector and as a result the human resources for health (HRH) challenge does not get better.

The other major challenge facing the health sector is the prevalence of technically unsound, politically misleading and financially nonviable decisions that are undoubtedly affecting the health care sector to an unbelievable extent. In developed countries, health professionals and policy makers make evidence based decisions regardless of the political consequences. They can turn down any health project if it does not meet required criteria. In Pakistan the situation is other way round. We follow “decision based evidence making process”. If a political leader comes to a decision to build a new 200-bed hospital in his or her constituency then no one at the health ministry will determine whether there is a genuine need for such a big hospital in the community? Ideally, a technical team from the relevant health ministry should visit the proposed area and prepare a comprehensive feasibility report before the construction is kicked off. I have seen many hospitals in Pakistan that are either vacant or underutilized.

Equity is another burning issue that is weakening the health care system in Pakistan. Resources are not evenly distributed across the country. If you compare a district hospital of Punjab with a similar caliber hospital in Gilgit Baltistan, then you will notice a huge difference. The former will have a good building, well equipped emergency department, lots of sophisticated equipment (like CT scan), ambulances and many specialist doctors. The later one will be consisting of a few rooms and will be at a disposal of a medical officer. You will neither find basic equipment (like x-ray, ECG) nor necessary life saving drugs.

Poor governance in the health sector has also led to misdirected spending of funds. Corruption in the procurement of medicines and equipment has defamed the health sector. There is no independent procurement body that can ensure transparency, quality and reliability. Political leaders and other influential people at the Ministry of Health issue contracts to their own friends and relatives and as a result hundreds of millions of dollars disappear each year.

On the other hand, hospitals are being provided with poor-quality equipment and medicines, both substandard and counterfeit. The government will be less worried about the situation if patients die after consuming substandard medicines. Just recently, seventy patients at Punjab Institute of Cardiology (PIC) died after consuming substandard medicines. Unfortunately till now, no action has been taken to identify and punish the culprits.

The Pakistani media has an important role to play to bring about a change in the country. It is said that media reflects society and holds up mirror to country’s political leaders. However, both electronic and print media have not yet truly pinned down health issues in Pakistan. Sit in front of the television and observe how many talk shows or discussions on key health issues have been on the air? Get up in the morning and go through the newspapers and see how many articles have been published on health and nutrition related problems?

The political leadership, health professionals, researchers and media should work together to strengthen the health care system in Pakistan. International agencies like World Health Organization, World Bank, UNICEF and USAID should play a larger and critical role in health care reform as internationally recognized, viable and uniform health policies are the real need of the hour in Pakistan.

                               Published in "The News International" on November 28th, 2012

September 01, 2012

AQIL SHAH - my role model and an inspiration in life

It was 7:00 am on a dreadful morning of August 22, 2012 when my mobile rang. I ignored it thinking that it was a blank call. Surprisingly, the phone went into hibernation for a little while and then started buzzing over and over again. The situation became extremely uncomfortable and even a bit scary when my wife’s cell phone also began to ring at the same time as mine.  The moment I picked up my mobile, it stopped ringing but a flash SMS popped up on its screen. It was sent by Rahman Posh (my brother in law) from Pakistan. The text message was as follow:

Dear Aziz, I heard a bad news that a van carrying BARATIS of Inayat from Kamaris - got into an accident and our beloved Aqil Shah and Bakhtullah passed away on the spot. May Maula rest their souls in eternal peace- Ameen
An unforgettable moment with Aqil Bhai during my wedding in
 Gilgit on March 14, 2009
The text message numbed my body, dulled my mind and soaked my eyes with tears. I could not believe what I just read.  I grabbed my laptop and immediately opened the "Pamir Times" an online Newspaper of Gilgit Baltistan. The horrendous road accident was the breaking news on the front page.  It was a tragic day for my entire family but alas, I was a thousand miles away from everyone. I was not in a position to pay my last homage to my late great cousin and beloved brother. I have never felt so helpless in my entire life.  At such a difficult time, the only person who consoled me in my grief was my wife. She right away dialed my sister number in Pakistan who along with my other family members was in a deep shock

Many days have passed since my lovely brother has died but the traumatic incident of August 22 is still fresh in my mind as if it happened today. I was looking for ways to cope with the situation and decided to let all my pain out through writing.  
 August 2005: Aqil Bhai with his eldest son in Islamabad

Three people have influenced and touched my life and contributed to what I am today. They were; my beloved mother, my incredible father and my adorable and caring brother Aqil. It  is said that some people come into your life for a reason and they change your life in ways you cannot imagine. Aqil Bhai was among the few people who left Gulmit for Karachi in the late seventies with a determined attitude, unbreakable will and a clear objective in mind to complete his higher education. It was a time when parents were reluctant to support such a decision. Like others, he forgot his sleep, worked nights and attended his college/university classes during the day. One can easily get to the intended destination- no matter how bumpy or steep the path becomes and Aqil Bhai proved it. He has an honor to be the first post graduate degree holder from very small villages of Kamaris and Odver. He also set an inspiring example for the younger generation. He was the first spark that ignited educational and social revolution in Gojal.  During his stay in Karachi, he supported thousands of students. His home was a ray of hope for all new comers. Even today, people love him like a father, remember him like a brother and respect him like a teacher.                                                                   
Aqil’s life took a new turn when he completed his education and returned to Gilgit Baltistan. He joined the Ministry of Tourism in Islamabad as a Tourism Officer and worked until 1994 when he took the responsibility of a Civil Supply Officer at the Department of Food and Agriculture in Gilgit Baltistan. Just a couple of years ago, he was promoted to the position of Deputy Director and remained in this position until his death. During his professional career, he never detached himself from his area. He continuously helped people, guided the young generation and actively participated in all types of social work.  He was not only a great social worker and a towering figure in Gojal but people from Ghizer, Hunza Nager and Diamer districts also remembered him as a kind hearted, generous and wonderful human being. Irrespective of his social status, he always lived a simple life. Unlike other government officials, he neither had any property nor owned a home anywhere in Pakistan. He lived in the rented property until his last day.

1985: A memorable family photo with Aqil Bhai in Gilgit 
when he came on vacation from  Karachi.
Aqil Bhai was not just a brother with a pure soul and golden heart but the relationship goes much deeper and beyond genetics or family ties. He was my greatest source of achievement, pride and inspiration. His selfless support has always been with me throughout my academic career. He always believed in my capabilities, instilled in me self confidence, taught me the meaning of life and pushed me to work harder to achieve my goals. I cannot forget those days when I was a third year student at Rawalpindi Medical College and my father was severely injured in an accident. We faced the worst financial crisis of our life. I could not pay my tuition and accommodation fees for months. At one point I became so helpless that I decided to relinquish my studies, return to Gilgit and take care of my family.  The moment Aqil Bhai heard this from a source in family; he immediately traveled to Islamabad and paid all my expenses. 

Aqil Bhai attended the last family wedding in Gojal on August 22, 2012
a  few hours before his death  [Courtesy: Asghar Khan]
He told me never to give up, be strong and work hard until I achieved my goals. The story does not end here. The list of his contributions is endless. I have no words that could truly represent my feelings.  Whatever I am today; it is all because of him. Aqil Bhai was and remains my childhood hero and I strongly believe that true heroes never die.  He has left a legacy for many generations. We will always fulfill his dreams that were left incomplete due to his tragic death and continue with his great mission. May God rest his soul in peace. Ameen

April 15, 2012

My Journey to Afghanistan

It was June 2004 when Focus Humanitarian Assistance Europe (an agency of Aga Khan Development Network) invited me for an interview at its office in Croydon, UK for a position based in Afghanistan. My thoughts were completely entangled with confusion. The western media was busy publishing and broadcasting horrendous stories about Afghanistan and at such a crucial time, going there would mean putting my own life at risk.  Nevertheless, I still decided to appear for the interview.

The most hard-hitting moment of the show was the day when I opened my email and found the job offer. I was indecisive, nervous and befuddled. I contacted Dr.Adnan – my best friend who was working as a medical officer at Ipswich mental hospital and told him about the situation.  In the meanwhile, I wrote to Dr.Sardar Ahmad – an old Afghan friend from medical school days who used to work for World Health Organization in Kabul. The two close friends suggested me to accept the job offer. I decided not to inform my family members in Pakistan about this life changing decision; I knew that they would not be very excited hearing about this.

I left London for Islamabad on July 3, 2004. After two days, I left for Gilgit to meet my parents and other immediate family members as I had not seen them for almost two years. After spending a very joyable week at home, I finally departed for Afghanistan – a country where I had never been before – never even thought to be there in life. It was not easy to be in Afghanistan soon after the 9/11 incident when its painful memories were still fresh in everyone’s mind. 

On July 12th, I took a United Nations Humanitarian Air Service (UNHAS) flight to Kabul. Remnants of war were still obvious at Kabul International Airport.  Wreckage of Soviet fighter jets and burned out tanks were lying near the run way.  The airport security personnel guided me to an immigration desk where a middle aged, male immigration officer looked at me and greeted me with a lift of his eye brows. I also returned the gesture. Before stamping my passport, he asked me something in Dari.  I had no idea what he said and remained silent. After a few minutes, I came out through the arrival gate and went to the parking lot where the office car was waiting.  The driver took me to a guest house located on the main Wazir Akbar Khan road. He mentioned that the United Nation Assistance Mission for Afghanistan (UNAMA) had been renting the building for many years. But now, it has been rented out to AKDN but everyone still called it "UNAMA guest house”. My room was on the first floor, facing the main Wazir Akbar Khan road and hence I found it a little bit noisy. I stayed in Kabul for a week, enjoyed delicious Afghani food and attended all orientation meetings before heading to Faizabad Badakhshan where I was to be stationed.

First arrival at Faizabad airport on July 26, 2004
On July 26th, FOCUS chartered a PACTEC plane to Faizabad (the capital of Badakhshan province). It was eight of us who were traveling to Faizabad.  We were directed to the aircraft without passing the security checkpoint. “Oh my Lord isn’t it too small” I asked one of my colleagues after first glimpse of the aircraft. I was very excited and was looking forward to an interesting journey. After a few minutes, we all boarded the plane. There was no cockpit door and it was interesting watching the two pilots as they navigated the plane towards our destination.  The co - pilot put our luggage in the trunk, closed the door and briefed us about the in-flight safety procedures without a live demo. It was my first ever flight without a stewardess or flight attendant. The PACTEC pilots were doing everything themselves.  The flight took off from Kabul airport around 11.00 AM and started flying over rugged hills and beautiful snow covered mountains of Kabul, Salang, Baghlan, Kunduz and finally Badakhshan. In the beginning, I was a bit scared because there was a lot of turbulence and on the top of that, it was my first time being on such a small aircraft. To cut a long story short, we finally arrived in Faizabad at 12.30 PM. The landing at Faizabad airport was an amazing and memorable experience of my life.  The Faizabad runway was made of metallic sheets and had been built by the Russians in 1980. As soon as the wheels touched the runway, we started hearing loud scraping sounds. Trust me, I was scared and was in a state of shock. When the propellers came to a complete standstill, one of the pilots said, “Welcome to Faizabad. We hope you have enjoyed your flight”.  He opened the door and asked us to leave the aircraft one by one. I took a deep breath of fresh air and immersed myself in the raw and beautiful landscape of Faizabad. I felt like I was in heaven when I stepped out of the plane. Focus Faizabad’s logistic and administration team members along with office vehicles were there to pick us from the airport. We were first taken to FOCUS guest house. I went straight to my designated bed room, showered and changed my clothes.  Later on, we went to AKF guest house for lunch. I really enjoyed Afghani food.  At the same time, I was introduced to Aga Khan Foundation (AKF) and Aga Khan Health Service (AKHS) team members. All of my colleagues were very friendly, warm hearted and welcomed me with open arms.  

Dr.Salim Sumar – Executive Officer of FOCUS Humanitarian Assistance –Europe and Dr.Iqbal Kermali –Country Director for FOCUS were also in Faizabad to help me acquaint myself with the area and ongoing projects. On the very first day, they took me to the office of Provincial Governor.  I still remember that moment quite well. We drove through a police guarded gate, followed the narrow trail through lush trees and shrubs until we got closer to an old building. We parked our vehicles and walked into this building. The entire building was made of mud and straw and had only three rooms. The traditional pit latrine was only a few hundred yards away from the building. The provincial or state governors in my own homeland live in beautiful buildings. The lavish decoration provides recognizable evidence of their wealth and importance. It is not possible for a common man to meet the state/provincial governor and share with him either personal or  community related issues. If you are lucky enough to get an appointment, the so called security procedures will definitely make you cry and you will regret your decision.

First official meeting with the  Provincial Governor of Badakhshan 
Let me rewind back to the original scene without going into too much detail. A guy - most likely governor’s assistant greeted us with respect and directed us to a room. When we opened the door a, middle aged, serious looking man with white beard greeted us with kindness but without a smile on his face. He was Sayeed Ikramuddin Masoomi - the provincial governor of Badakhshan. One of our local Afghan staff introduced us to his Excellency Provincial Governor and his team.  In a nutshell, he welcomed us open heartedly, appreciated Focus’s contribution and asked us to do more for the poor and deprived people of Badakhshan. As a gesture of welcome, we were offered black tea (Chai), sweets and dried mixed fruits displayed on a tray in a traditional style.

On our second and third days, we visited UN agencies and other government departments in Faizabad. The orientation period that lasted for almost a week went very well. At least, I had some idea of what life looked like in Badakhshan and what were the real challenges.  At the same time, I was also perplexed and in state of imbroglio as I had no experience of managing multi-million dollar programs in post conflict countries like Afghanistan. There were many unanswered questions in my mind.  I was constantly asking myself, “Would I be able to comply with the expectations of the people and Afghan Government? Would I be able manage and keep my staff happy? Would I be able to do what the senior management was expecting from me?”  My heart's deepest inner feelings boosted up my self- confidence and aroused my enthusiasm and forced me to say, “I can, I will”.
Last but not the least; I worked for Focus Humanitarian Assistance (Europe) for almost two years. During my stay in Faizabad Badakhshan, I faced some tough times. I cannot forget the Faizabad incident when AKDN offices and guest houses in Faizabad were burnt, two other colleagues and I were made hostage and beaten by an angry mob in September 2004. I also can never forget the Baharak incident when some unknown people lobbed a hand grenade at my guest house - Ehsan Assad (my colleague) and I got minor injuries but luckily survived the incident.  I will go into more detail about these incidents some other time.  At this point, I can only say that these ill-fated incidents never bewildered or frightened me at all. My courage, pride and determination were never influenced by these events. I never lost my belief and confidence in the people of Badakhshan. I always prayed to God to give me the true strength and courage to serve these people.

With Shohada community members and Mission East staff
In August 2007, I joined Mission East (Danish NGO) and it was another golden chance to work with the hospitable people of Badakhshan.  I had a very strong affiliation and deep attachment to the land and people of Badakhshan not only because I lived and worked here before but also the place in Gilgit Baltistan where I was born and bought up, the language I spoke, the type of food I ate, the kind of music I listened and the form of dance I liked – were also a few considerable reasons behind this connection. North Pakistan (now called Gilgit Baltistan), Badakhshan Afghanistan, GBAO Tajikistan and Xinjiang China have so many things in common. Same landscapes, same beautiful snow covered mountains, same food, same religion, same customs, and same language are bringing together people from four different countries.

The two and a half years stay with Mission East was an amazing period of my life. It was one of the best international organizations to work for in Afghanistan. This organization has done so much to increase access to safe drinking water supply and sanitation services in North East Afghanistan.

With AKHS - health team in Darwaz District of Badakhshan
In January 2010, Aga Khan Health Service Afghanistan (AKHS-A) provided me with an exceptional opportunity to design, implement and oversee the community health programs in the province of Badakhshan. Badakhshan drew international media and donor agencies attention in 2003 when a joint survey report of UNICEF, CDC and Ministry of Public Health Afghanistan (MOPH-A) revealed that Badakhshan had the highest recorded rate of maternal mortality [6,500/100,000 live births] in the world.
I feel not only lucky but blessed to be part of AKHS-A, MOPH, USAID, UNICEF and other development agencies in Afghanistan to come up with effective strategies to implement long term health partnership programs in Badakhshan. AKHS-A also provided me with a golden chance to work on some new innovative projects that have rarely been executed in the world. The cross border health program between Afghanistan and Tajikistan was one the most amazing and memorable project that I have ever come across in the twelve years of my career. Every day, every hour and every second that I spent with AKHS were the most creative periods of my life.

The prolonged, impressive and memorable journey of six years came to an end in January 2012 when I decided to bid farewell to Afghanistan to join my family in Texas USA.

With Badakhshan Midwifery School students and faculty staff
Afghanistan will never fade away from my memory. Every morning I get up and miss the beautiful mountain landscapes of Badakhshan when I look out the window from my house in Sugar Land, Texas. I really miss my friends, colleagues and above all, the friendly, peaceful, loving, warm and hospitable people of Badakhshan. I have no words to express my feelings to those other than to say “thank you”. You will always have a special place in my heart.  I will never forget those difficult days when you took me to your house and saved my life when the security situation worsened in Faizabad.  I will never forget your kind hospitality and warm welcome to your house on Eid, Novroz and other occasions when I was alone in my guest house.   How could I forget the rocking farewell parties you organized, those beautiful words you spoke and the wonderful gifts you gave me when I was leaving Afghanistan?

With Dr.Nadira Hayat- Afghanistan's Deputy Health Minister
My journey to Afghanistan would be incomplete without recognizing the people who supported me along the way.  My special thanks go to Dr.Salim Sumar [who is the Chief Executive Officer for FOCUS Humanitarian Assistance Europe] for providing this wonderful opportunity to come and work in Afghanistan. I was always on my toes in my career because of him.  I am very grateful to Jacques Dailoux (who was the Desk Officer for Mission East in Brussels) for giving me a fantastic opportunity to work with a well respected organization in Afghanistan. It would not be an exaggeration to say that I have yet seen a humble person and true professional like him in my career.  It will be a great injustice if I do not thank Dr.Gijs Walraven- Director of Aga Khan Health Services (in Aiglemont France), Dr.Nayamat Shah (former Country Director for AKHS program in Afghanistan) and Dr.Fatima Mohbat Ali (Regional CEO for AKHS in Afghanistan and Central Asia) who believed in my capabilities and gave me the opportunity to work for Aga Khan Health Service in Afghanistan.  

With Excelleny David D.Pearce- U.S Ambassador to
Afghanistan and Dr. Waliullah -  Governor of Badakhshan
Last but not the least, Afghanistan not only developed my career but it also brought a special aroma to my personal life. This beautiful land blessed me with an opportunity to meet and marry my beautiful wife –Shazia Nota. My journey to Afghanistan would have not been possible without her never-ending love and support. She lived without me in USA for so many years but encouraged me to work for the people of Afghanistan for such a long duration. Thank you so much my love!

Although my six years journey has now come to an end but the beautiful memories will continue to live in my heart and mind forever.