The Gateway Paper; Health systems in Pakistan - A way forward, Mental Health: An Indian Perspective 1946 - 2003

January-June 2006 Volume 3(1)

Book Review

Page No:


The Gateway Paper, Health systems in Pakistan – a way forward

By Sania Nishtar. Heartfile Central Office, 1 Park Road, Chak Shahzad, Islamabad, Pakistan. 2006. 199 pp.



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The first book review in JPPS is about a publication on the health system in Pakistan. Just a chance association? Considering the editorial in this issue is about public health intervention in psychiatry, the association is more than a chance. It is highly significant relationship which we want to foster between the two disciplines and you will see more on this. Watch this space!


The author introduces the paper in the précis as “the Geteway paper is a product of the consensus driven Action Plan embodied within the statement of Pakistan’s Health Policy Forum, a recently established health- sector think tank designed to stimulate, assist in the development of and monitor health policies; foster their implementation and catalyze change through technical and policy support”.


The paper elaborates the present health system in Pakistan and makes a strong case for reforms in the health system. It reviews the basic functions of a health systems i.e. stewardship, financing, service provisions and inputs. The first major section of the paper highlights the role of state as steward and regulator. It points out rightly that the major reason for policy failure and implementation has been the paucity of locally applicable evidence and perhaps even worse no use of existing available evidence. It is of course a refreshing change in the present climate of debate on health systems that a document starts with a need for the evidence based solutions and the emphasis on this is evident throughout the book.


The next section elaborates on the present system of health financing in Pakistan. The author makes a good case for not relying on taxation as sole source of financing health in Pakistan. A highly valuable feature of this section is the statistics provided on various aspects of health financing in Pakistan. This, perhaps is one of the few resources where you can find basic and highly relevant data about the health system financing in Pakistan. We are told, for example, the startling fact that the average out of pocket expenses on health are equal to 5.2% of total monthly house hold expenditure of an average Pakistani family and poor bear a heavier burden of medical costs than the rich. “Donors contribute to only 14.7% of total public health sector allocation, this plays havoc with the health system by determining all the major priorities in health sector, made even worse by the lack of local capacity.”


Another section, comprising of three substantial chapters reviews the delivery of health services, both in public and private sector. This is followed by a highly informative debate on federal-provincial-district partnerships in governance. In a critical review of the present decentralization policy, the author points out that “Political and administrative decentralization has also paradoxically created centralization of some functions within the district itself”. It is also rightly pointed out that “the real challenge in relation to political and administrative decentralization is for it to go side by side with empowerment and devolution of power at the grassroots level”.


The paper also highlights the need for proper human resource management, a robust drug policy and legislation, health promotion and research. The question “why has there been a failure to foster a research promoting culture in health sector”, is also discussed. (The simplest answer would be we are not fond of ‘culture’!) I expected a detailed discussion, because this is the root cause of many problems we are facing but had to contend with only one page.


My only disappointment is a rather brief discussion of mental health in the context of the health system delivery. This should not be taken as the view of a specialist demanding a lion’s share for his territory. This concern stems from robust evidence which shows that the low priority assigned to mental health is a major cause of ill health systems in developing countries including Pakistan1.


The title is highly relevant; this is the ‘gateway’ paper and it is hoped that it will pioneer the future policy directions in the country. This paper is a must read for anyone who has some interest in the health care and health system in Pakistan. I will recommend this for all the policy makers, managers in health systems and clinicians with interest in public health. It is very valuable addition to an otherwise scanty literature on health systems in Pakistan which has been plagued by an ugly divide between clinical and public health profession. Coming from an author who is a cardiologist, this book should also help to bridge this gap. This paper aims to initiate dialogue on health system in Pakistan. Considering, the present state of health system in Pakistan this is need of the hour. I certainly found the paper very stimulating and highly informative.


The presentation and style is user friendly. The author sets herself few questions in each topic and then provides answers to these. The book is available from the Heartfile central office (E-mail:



World Health Organization. Investing in mental health. World Health Organization, 2003. Geneva.


The book Mental Health. An Indian Perspective.1946-2003

By S.P. Agarwal. Director General of Health Services, Ministry of Health and Family Welfare India. New Delhi. 2005. 532 pp. ISBN 81-8147-195-4. The book Mental Health, An Indian Perspective is a remarkable effort by S.P. Agarwal that analyses the current situation of mental health care delivery in India in the light of a carefully reviewed historical perspective. It is particularly interesting for a Pakistani reader for our socio-cultural, economical and geo-political set up is pretty much the same. We share the history and many problems in health care delivery in which we can learn from each others experience.

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What we found to be the most remarkable feature of the book was its non-judgmental and unbiased evaluation of the material and facts. The data presented has been extensively collected from various resources and has been carefully and concisely summarized. The assumptions and postulations are carefully formulated and evaluated critically.


The book attempts to focus on the modern concept of Mental Health rather than dwell too much on the older concepts of folk remedies of mental maladies and starts with a retrospection of the British conquest of the sub-continent that started in the East and South and moved towards West and North. After occupying a sizeable portion of India, The British started introducing many services and systems, most of the models were naturally taken from their own country. This section emphasizes and describes the adequacies and inadequacies of the facilities provided. Without being judgmental, it explains how significant was the contribution of the British in this regard and yet how limited it was since they only improvised them far enough to suit their specific needs particularly in to realm of aiding governance.


 A few asylums were housed in dilapidated army barracks or prisons in the major urban centers. The asylums were mainly for British soldiers or Indian Sipahis serving the British. These facilities did not cater for the general population. The asylums were inadequately staffed and poorly provided.


The book then moves on to discuss the steady, albeit slow leaning away from the “custodial” style of care towards a less stigmatizing and more patient oriented hospital system of care. This started happening in the colonial times. The focus moved away from labeling the afflicted as “lunatic” needing an “asylum” to calling him the patient and needing mental health care.


In the early days after independence, the focus in mental health was to improve trained manpower and integrate mental health with general health. The birth of Indian Psychiatric Society and its role in shaping future policy is highlighted. A remarkable milestone was reached with the appearance of Indian Journal of Psychiatry.


The practical difficulties of conducting epidemiological surveys are also dealt with in detail. The problems of methodology and nosology are also discussed. A significant detail of major illnesses and surveys conducted is given in a very organized fashion.


In addition to streamlining the mental health services there was a crucial question of updating Lunacy Act of 1912 and replace it with a new law which should reflect the changes that have taken place in the world of psychiatry. After decades of struggle Indian psychiatrists pushed through Mental Health Act of 1987 but many years after its approval by the parliament there was little change on the ground. The book describes very well how it still retained its British flavor. The concept of lunacy and the focus on saving the common man from the lunatic remained dominant for a long time and even now.


The author takes the reader step by step as to how the Indian mental health program kept lurching forward amid the chaotic disorganization in the political and professional circles. It describes the efforts of National Mental Health Programme to develop a broader base of multidisciplinary mental health care, the birth of community psychiatric health care at the NIMHANS (National Institute of Mental Health and Neurosciences) program and the development of rural mental program in Chandigarh.


It pays special attention to the tragedy of Erwady in the Ramanathapuram district of Tamil Nadu which led to the first ever solid involvement of the judicial and litigation system in the care of mentally ill. This paved the way for very vigorous and reasonably coordinated effort to evaluate the true state of mental health care in India in October 2001.


Next the book addresses the various aspects of mental health care one by one and the efforts done by various sections of the government, WHO and the professional and civil society. The last part of the book absorbs the readers with some very nice chapter in “down the memory lane”.


The appendices are a voluminous section of information that provide almost every single detail of official documents and laws, and provide an exhaustive account of manpower and services available in India. The Mental health act of 1987 as well as Mental Health rules 1990 are documented with definitions and descriptions.


The editors, associate editors (D.S. Goel, R.L.Ichpujani, R.N.Salhan and S.Shrivastava) and all the authors of the different chapters must be applauded for this splendid work. The script was eloquent and the language simple. Apart from the fact that it takes time to go through this voluminous book (530 pages), it was a very pleasant reading as well as a learning experience to review this book.


We hope that professionals from our part of the world would keep taking such initiatives and provide such helpful material. We recommend this book to any reader in general and anybody involved in policy making and organizing mental health care in the developing world in particular.