Comment
disease are often more complex than the inability to
reliably measure blood pressure.
Despite such complexities, WHO’s initiative to support
the development of a simple, affordable, solar-powered
device should be lauded. Hopefully, other cheaper devices
(eg, for cardiac ultrasound) will be developed to detect
other important conditions, including rheumatic heart
disease and pericarditis.9 But a market for such devices
(with competition between manufacturers to drive
prices down) needs to arise in low-to-middle-income
countries. Ultimately, a sustainable platform of research
funds is needed to tackle an increasing burden of noncommunicable cardiovascular diseases in these countries,
via multifaceted prevention programmes (with devices
such as the HEM-SOLAR) to reliably detect at-risk
individuals and monitor the effect of combined pharmacological and non-pharmacological interventions.
*Karen Sliwa, Simon Stewart
Hatter Institute of Cardiovascular Research in Africa, Department
of Medicine, Faculty of Health Sciences, University of Cape Town,
7935 Cape Town, Western Cape, South Africa (KS); and Baker IDI,
Melbourne, VIC, Australia (SS)
sliwa-hahnlek@mdh-africa.org
SS thanks the National Health and Medical Research Council of Australia for
funding. SS is a principal investigator of a hypertension trial sponsored by
Novartis Pharmaceuticals Ltd Australia and of a hypertension-awareness study
sponsored by Schering Plough Ltd Australia. KS declares that she has no conflicts
of interest.
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Mayosi B, Flisher AS, Lalloo UG, Sitas FS, Tollman SM, Bradshaw D.
The burden of non-communicable diseases in South Africa. Lancet 2009;
374: 934–47.
Stewart S, Sliwa K. Preventing CVD in resource-poor areas: perspectives
from the ‘real-world’. Nat Cardiol Rev 2009; 6: 489–92.
Stewart S, Libhaber E, Carrington M, et al. The clinical consequences and
challenges of hypertension in urban-dwelling black Africans: insights from
the Heart of Soweto Study. Int J Cardiol 2011; 146: 22–27.
Parati G, Kilama MO, Faini A, et al. A new solar-powered blood pressure
measuring device for low-resource settings. Hypertension 2010;
56: 1047–53.
Stewart S, Carrington M, Pretorius S, Methusi P, Sliwa K. Standing at the
crossroads between new and historically prevalent heart disease: effects of
migration and socio-economic factors in the Heart of Soweto cohort study.
Eur Heart J 2011; 32: 492–99.
Geneau R, Stuckler D, Stachenko S, et al. Raising the priority of preventing
chronic diseases: a political process. Lancet 2010; 376: 1689–98.
Mendis S, Abegunde D, Oladapo O, Celletti F, Nordet P. Barriers to
management of cardiovascular risk in a low resource setting using
hypertension as an entry point. J Hypertens 2004; 22: 59–64.
Lock K, Smith RD, Dangour AD, et al. Health, agricultural, and economic
effects of adoption of healthy recommendations. Lancet 2010;
376: 1699–709.
Sliwa K, Carrington M, Mayosi BM, Zigiriadis E, Mvungi R, Stewart S.
Incidence and characteristics of newly diagnosed rheumatic heart disease
in urban African adults: insights from the heart of Soweto study.
Eur Heart J 2010; 31: 719–27.
Pakistan prepares to abolish Ministry of Health
Published Online
May 5, 2011
DOI:10.1016/S01406736(11)60606-5
648
Politics in Pakistan could leave an indelible mark on
health. The country’s Parliament has signed off on
a constitutional amendment that paves the way for
the abolition of the Ministry of Health. By June this
year, Pakistan could be the first country without an
institutional structure—a ministry, state department,
directorate, or equivalent structure—at the federal level
in charge of national responsibilities for health.1 This
amendment comes at a time when there is a dire need
to increase the capacity of the health system in view
of many serious challenges. For example, the failure
to eradicate poliomyelitis means that Pakistan might
be the last remaining reservoir of endemic poliovirus
transmission in the world.2
At the broader level, the 18th constitutional amendment has undone some of the distortions introduced
in previous years under successive military rule, and has
restored some degree of parliamentary democracy to
Pakistan. The amendment has granted provinces greater
autonomy, and has devolved decision making in many
sectors including health. In principle, devolution of
powers can improve governance and has the potential to
improve health equity. However, it is vital that national
health matters are identified, and related responsibilities
are entrusted to a federal institution.
There are many national responsibilities for health
in federal systems, including health information,
regulation, international commitments, trade in health,
establishment of policy norms and standards, and
interprovincial policy coordination. These responsibilities
have to be centrally managed in federations as is
the case in the USA, Switzerland, Argentina, Nigeria,
Ethiopia, and elsewhere. Pakistan is faced with many
health-system challenges in each of these areas. Trade
in health demands critical oversight. The burgeoning
of kidney transplant tourism is an indicator of eroded
capacity within the existing system. Migration of
human resources to neighbouring oil-rich gulf countries
is causing a brain drain. Pakistan’s failure to comply
with WHO’s International Health Regulations (2005),3
www.thelancet.com Vol 378 August 20, 2011
confirmed in the under-reporting of H1N1 influenza last
year,4 is indicative of weak health information capacity.
The regulatory body for health workers has had tenuous
relations with the Ministry of Health over the division
of duties, and has performed poorly. Additionally,
weak drug regulation has resulted in an increase in
counterfeit drugs and has led to independent actions
by Pakistan’s progressive superior court. There has been
no progress on a 2002 cabinet decision to establish
an independent drug regulatory authority, with little
recognition that such an organisation will be needed if
the country is to benefit from the key flexibilities under
the Trade Related Aspects of Intellectual Property Rights
agreement. The move to devolve drug regulation when
several countries are moving towards regional models
of regulation is questionable. These problems create an
imperative for increasing health system capacity, rather
than abolishing the Ministry of Health. An appropriate
federal agency can help by sparing provinces from
duplicative work for which they neither have institutions
nor resources. Efficient use of resources is particularly
important, because Pakistan’s fiscal situation under an
International Monetary Fund programme is tight, and
funding is further stretched by the demands of fighting
an insurgency and rebuilding after the floods of 2010.
The commission responsible for implementation of
the amendment could suggest a so called cut and chop
formula to retain national functions at the federal level.
There is a precedent, evident in devolution of other
areas, such as education and family planning, by which
functions have been divided and distributed to different
federal institutions. However, such fragmentation
will worsen existing capacity constraints in health. A
constitutional route to retain a federal health entity
exists and should be taken.5 This constitutional route
also presents an opportunity to reorganise the Ministry
of Health, which was never structured properly for
national functions and therefore did not have sufficient
capacity. In tandem, support for devolution should be
garnered where success is measured by the creation of
both an effective central state, which does not exist in
Pakistan, and a functioning local government system,
which has been in flux since changes were introduced to
the system in 2002.
Global experiences show how constitutional provisions
can assist health systems through the enshrining of
health rights, as is the case in many other countries,
www.thelancet.com Vol 378 August 20, 2011
Shehzad Noorani/Majority World/Still Pictures
Comment
A community health worker in Grax, a village on the outskirts of Karachi, Pakistan
and through access to treatment in countries where the
right to health is guaranteed under the constitution and
where courts can enforce provisions. Examples from
Latin America6 show the potential effect of changes in
constitutional statutes on policy shifts in the health
sector. Pakistan should not set a wrong precedent that
could encourage federal units (provinces or states) in
other countries to demand the abolition of a federal
role in health. Future decisions should be guided by the
overarching provisions in Pakistan’s constitution that
morally bind the state to reduce inequities in society.
*Sania Nishtar, Ahmed Bilal Mehboob
Heartfile, Chak Shahzad, Islamabad, Pakistan (SN); and Pakistan
Institute of Legislative Development and Transparency,
Islamabad 44000, Pakistan (ABM)
sania@heartfile.org
We declare that we have no conflicts of interest.
1
2
3
4
5
6
The 18th Amendment to the Constitution of the Islamic Republic
of Pakistan. 2010. http://pakistanconstitution-law.org/18thamendment-2010 (accessed April 13, 2011).
Global Polio Eradication Initiative. 2010. http://www.polioeradication.org/
InfectedCountries/Pakistan.aspx (accessed April 13, 2011).
WHO. International Health Regulations (2005). http://www.who.int/
ihr/9789241596664/en/index.html (accessed April 28, 2011).
Nishtar S. H1N1 in Pakistan: lessons learnt. NTS working paper series.
Paper number 4. Centre for non-traditional security studies, Singapore.
2010. http://www.rsis.edu.sg/NTS/resources/research_papers/
NTS%20Working%20Paper4.pdf (accessed April 27, 2011).
Nishtar S. Health and the 18th Amendment. Heartfile. May, 2001.
http://www.heartfile.org/pdf/HEALTH_18AM_FINAL.pdf (accessed
April 20, 2011).
Clapham A, Robinson M, Mahon C, Jerbi S, eds. Realizing the right to
health. Switzerland: Rüffer and Rub, 2009.
649