Population and Health Policy Data for Policy Making

January 11, 2009

Talks & Interviews

Mohammad Nizammuddin

The panel discussion was chaired by Prof. Dr. Mohammad Nizammuddin Vice Chancellor, University of Gujrat and moderated by Dr. Arshad Mahmood Director Monitoring & Evaluation, Population Council. The panelists included Dr. Mehtab S. Karim Senior Research Advisor Pew Research Center, Dr. Inam ul Haq Senior Health Specialist The World Bank Islamabad and Mr. Mehboob Sultan Former Director National Institute of Population Studies.

Karim started his presentation by defining policy as a course of action adopted and pursued by a government, party, ruler or a statesman which has political implications and is thus constrained by both domestic and international political, socio-cultural and economic pressures. He considered policy making as a non-linear, complex and multifaceted process aimed at finding solutions to specific problems. Thus it ought to be evidenced based rather than being limited by the non-technical background of policy makers. Additionally the evidence needs to account for the interest of different stake holders who are affectees or sponsors but have to be a part of the solution.

However, in Pakistan instead the “Garbage Can” model is followed for policy making where problems, stake holder interests, bureaucracy’s opinions and politician’s stake are all put in a trash can and out comes a policy without any logical basis or reasoning usually ignoring an evidence based decision making process. Karim highlighted mutual stereotypes. While policymakers are considered uninterested having limited perspective, are distrustful of researchers and not inclined to draw implications from data, the researchers instead are thought to usually avoid policy implications of their findings, are incomprehensible by their use of excessive technical jargon and provide inconclusive generalizations about broad theoretical matters with little appreciation of real problems.

Karim examined both the theoretical as well as the practical aspects of policy making process. Theoretically, the decision-making process entails prioritizing goals and objectives, systematically examining alternative solutions, practicing rational decision-making and choosing alternatives that maximize benefits. Practically, policy making is a political art form that creates a window of opportunity for policy development through the interplay of policy agenda setting and stake holders’ coalition building to devise policy decisions. Policy agenda entails setting clear, measurable indicators, and attention-focusing milestones while providing feasible policy or program alternatives for discussion. Coalition Building requires linking together individuals from the government, academic community, NGOs, advocacy and citizen representative groups, commercial sector and other stakeholders such as the media. Their interplay involves utilizing research findings to explore implications of policy alternatives before formulating actual policy recommendations. Analyzing implications serves as a bridge between key research findings and policy recommendations by providing guidelines to policy makers in interpreting the findings and collectively critiquing the direction for alternative policy options. Thus helping formulate policy recommendations which are specific, measurable, action-oriented, realistic and time bound.

After discussing the conceptual definition of policy making, Karim posed the question ‘Can this actually be done in Pakistan?’ and proceeded to answer. He stated that the prerequisites were appropriate and accurate data in addition to a willingness to utilize this data for policy making. There were three sources of demographic and health data: the census, registration of vital events and sample surveys. But in Pakistan there was no registration system while the latest census had been delayed. Therefore, researchers could only rely on sample survey data.

… unfortunately there was no integration of available data. More importantly this data had been used rarely for policy formulation.

Still there was no lack of data at least in population and health related issues as several national surveys had been conducted in Pakistan in the last two decades including Pakistan Demographic & Health Survey: (1990-91, 2006-07), National Health Survey of Pakistan: 1990-94,

Pakistan Family Planning & Fertility Survey: 1996-97, Pakistan Integrated Household Surveys (various years) and Pakistan Reproductive Health & Family Planning Survey: 2000-01. In addition, population and health related data was also routinely collected at the grass root level, at district and provincial levels through several small scale surveys confined to specific geographic areas/groups by the government, NGOs and other sources to address local population and health issues. But unfortunately there was no integration of available data. More importantly this data had been used rarely for policy formulation.

Haq raised other aspects of research data acquisition. He stressed the need for an organizational structure to collect data and considered institutionalization as the key difference between the health and population sectors. Population sector had an institutional structure for collecting, aggregating and analyzing data that was lacked by the health sector.

He stated that the following categories of data need to be collected for population and health: 1) Population & Health Outcomes 2) Services & Immunization Coverage 3) Human Resource, Financial and Infrastructural Outcomes 4) Disease Term & Epidemics and 5) Risk Factors & Behavior. More importantly the bigger picture needed to be kept in mind with a clear vision of the use of data before it’s collected. Only then a proper assessment of the tradeoff between relevance and comparability could be made to identify items requiring measurement. Substantiating his argument with an example, he stated that although there was a mix of both public and private in population and health sectors, very little data was available for the private sector indicating a lack of vision and sector based holistic strategy.

The lack of results based culture at the root of Pakistan’s governance problems as it limited the systems ability to deliver and did not allow for evolving a clear strategic vision to outline objectives and results.”

Pakistan did not have real time information collection especially of infant and under five mortality rates. No system existed to track risk factors and behavior while disease surveillance mechanism only existed for Polio. There was no coordination in the functioning of various government departments and no integration among their various information systems. Instead, the predominantly used Sample Data was intermittent allowing analysis of early data sets while exploration of time series data and trends required extensive individual effort by researchers. Haq considered the lack of results based culture at the root of Pakistan’s governance problems as it limited the systems ability to deliver and did not allow for evolving a clear strategic vision to outline objectives and results. It complemented the inadequate emphasis on the state to collect and analyze data, to monitor and conduct performance evaluation of various sectors and to improve the poor organizational capacity both at the provincial and federal level. Though policies existed, they were general, immeasurable leaving the state unaccountable with little emphasis on building institutional capacity for public sector appraisal. No wonder Pakistan had started to lag behind other South Asian countries in development indicators. Haq ended with a note of hope by providing an example of the initiative of the Pukhtoonkha government to measure disaggregated district level information in the health sector which would allow for performance analysis.

Sultan seconded Haq in putting the onus on the Pakistani State to fulfill its critical function of collecting data to track results of running policies arguing instead that it was lack of state’s accountability towards the populace that had led to a lack of interest in funding data collection activities. When the motivation for policy making was other than benefiting the populace, there was no need to promote a results based culture or to formulate evidence based policy. While accepting differences in research capital between health and population sectors, he disagreed that organizational structure did not exist in the health department citing the example of Pakistan Medical Research Council (PMRC), which had a large budget but produced no results. Thus existence of a structure did not matter if there was a lack of political will and institutional capacity to deliver.

He suggested that the reason for uneven distribution of collected data in Pakistan was thawere a donor driven activity requiring large funding and professional capacity. Population just happened to be more important for international donors as compared to health while the actual responsible party; the State had no research agenda. Thus supporting the argument that family planning’s domination of Population Policy is an outcome of donor bias, lack of evidence based analysis of family planning program constraints and of not exploring alternative options.

“It was lack of state’s accountability towards the populace that had led to a lack of interest in funding data collection activities.”

The overall consensus among the panel was the dire need to promote results based culture in policy making which required political will, institutional capacity building and closing the loop of data collection, analysis and evidence based policy making. Though enough data existed, it was not integrated like the Scandinavian ‘Data Central’ which linked together frequently acquired multiple data modules for near real time analysis. Additionally, there was a lack of data mining exercise even though it was cheaper than data collection. The recent PDHS data set which had sampled 100,000 households provided ample data for analysis such that no one person or even an institution could analyze the complete data set. It was thus suggested that a working group be established to serve as a bridge between researchers and policy makers with members drawn from key ministries, academics and NGOs to support evidence based policy making. But most importantly it was the state that had to support the development of a results based culture by facilitating this collaborative process.