UQ, a dear friend, sent me this message with a most well written and incisive piece below:
This is a bit long but I request -indeed humbly insist- that you read it through. This is a shockingly sad -and true- reflection of the development aid in Pakistan. I hope and wish that some discussion starts happening at least in our office(s) about the possibilities to redress the issues mentioned in this article.
Samia Altaf, a public-health physician who has worked in the United States and Pakistan, is the 2007-08 Pakistan Scholar at the Wilson Centre. She is currently at work on a book about aid effectiveness in the health sector in Pakistan.
by Samia Altaf
For our meeting with the director of the Pakistan Nursing Council, we
arrived punctually at a small two-room office tucked away in a corner of the
National Institute of Health’s campus in Islamabad. In the center of one
room was a table covered with a flowered plastic tablecloth, as if awaiting
a picnic. Resting on it were a pencil holder, some writing materials, and a
telephone. On one side of the table was a rather ornate chair, and on the
wall behind it was a framed photograph of Muhammad Ali Jinnah, the man
credited with creating Pakistan, in his signature oval cap and a severe
black sherwani, a formal knee-length coat. Four rickety chairs, a bit dusty,
lined the other side of the table. In the adjoining room were more rickety
chairs and another table, on which an elaborate tea service was arranged. A
small man wearing stained clothes sat on a stool by the door, and mumbled
something as he rubbed sleep deposits from his eyes.
“She’s what?” I heard my companion ask in a panic-stricken tone. “Dead! Oh,
my God, do you hear that?” she said to me. “The director of the nursing
council is dead.” She stood still for a minute, as if paying her respects.
“How did she die?” she said, again turning to the fellow.
The man looked offended at our misapprehension. “Late. Mrs. S.,” he said.
Ah, Mrs. S. wasn’t dead. She would be late.
My companion, a Canadian, was new to this part of the world and
understandably confused by the way Urdu, the national language, is
translated into English, the “official” language, especially by people who
have minimal schooling. Mrs. S. had gone from merely being late to being
“the late Mrs. S.” In a way, this slip of the tongue-or of the ear?-was
quite symbolic. For in its efforts to make any effective contribution to the
changing needs of the health care system, the Pakistan Nursing Council-the
federal institution that oversees nursing and all related professions-might
as well have been dead.
We told the man that we would wait.
For the past several weeks, my Canadian colleague and I had been traveling
through Pakistan as we prepared recommendations for a technical assistance
program funded by the Canadian government. She was the external consultant
on this project, and I was the local consultant. A pale woman in her early
forties, she was dressed that day in loose trousers and a neutral-color top.
Privately, I had taken to calling her “Lucymemsahib,” after a character in
Paul Scott’s novel of postcolonial India, Staying On (1977), who exemplifies
the imperialist attitude of British hangers-on. True to this model, Lucy had
been undergoing a memsahib-like change by barely perceptible degrees each
day. Both of us were at times in each other’s way, at times at
cross-purposes. We were unsure of who was actually in charge-she, by virtue
of her status as “lead” consultant, or I, more experienced, though a “local”
and hence inferior.
Mrs. S. arrived an hour later quite flustered. She was a shy-seeming,
slightly built woman in her fifties wearing a flowery shalwar-kameez. On her
head was a starched dupatta-a long scarf-from which raven black hair peeked
out. Dyed, no doubt. She looked a bit startled to see me in a sari,
wrinkling her nose delicately in what I interpreted as disapproval as she
adjusted the dupatta with an elaborate gesture.
“You are not a Pakistani?” she asked, affecting nonchalance.
I told her that I was, and could see that she did not believe me. Why, then,
was I wearing a sari? The traditional sari-a single piece of cloth wrapped
around the body-is worn by subcontinental women of many religious and ethnic
backgrounds. Pakistani women wore saris until the 1970s, when in a period of
Islamo-nationalist fervor, and with the tacit encouragement of the
government, they adopted the shalwar-kameez-dupatta ensemble-loose, baggy
pants and a long tunic with two yards of loose cloth that drape the
shoulders. The rejected sari acquired an “Indian” tinge, and came to be seen
as vaguely “Hindu” as well as anti-Islamic, a sentiment that hasn’t entirely
Mrs. S. apologized for the delay, telling us that she had been called away
unexpectedly. “Must have been something important,” I said conversationally,
for she was quite out of sorts. I worried that my sari-clad personage was a
contributing factor. This turned out not to be the case. A World Bank
delegation was visiting, and she had been called to meet them “right away.”
Couldn’t she say that she had an earlier meeting and have them wait?
Lucymemsahib wanted to know.
“How can you do that?” Mrs. S. asked. “They are the World Bank.”
And now, she asked, what could she do for us?
The year was 1992, and Lucymemsahib and I were helping the government of
Pakistan prepare a grant proposal for the country’s Social Action Program
(SAP)-a comprehensive effort to renovate Pakistan’s health, education, and
water sanitation systems that the World Bank and a consortium of other
multinational development organizations had pledged to support.
Specifically, we were looking into ways to attract more women to provide
midlevel health services in rural areas. As head of the Pakistan Nursing
Council, Mrs. S. presided over the governmental organization responsible for
the recruitment, training, and certification of nurses at Pakistan’s 60
civilian nursing schools and a handful of specialized military institutions.
The SAP we helped prepare, which ran from 1993 through 1998, turned out to
be a dismal failure, as was the one that followed in 1999-2003. Subsequent
programs, especially since 9/11, show every indication of being as
unsuccessful. The critical indicators of maternal and child health tell it
all. Estimates of Pakistan’s maternal mortality ratio since 1990 range from
300 to 800 maternal deaths per 100,000 live births; even the low end of this
range is unacceptable. By contrast, Sri Lanka, another South Asian country,
with an income per capita that was roughly comparable to Pakistan’s at the
beginning of the 1990s, saw its maternal mortality ratio fall from 92 per
100,000 in 1990 to below 50 today. The infant mortality rate in Pakistan in
2003 was 76 per 1,000 live births, as compared with 11 in Sri Lanka. In the
developed countries, the infant mortality rate is only about five per 1,000
Beyond the health care sector, the story is much the same. A report
published in 2007 by the Center for Strategic and International Studies in
Washington, D.C., concluded that the $1 billion in development and
humanitarian assistance the United States has poured into Pakistan since
9/11 has saved lives in areas affected by a massive 2005 earthquake and has
improved the lot of a small number of people, but “has done little to
address the underlying fault lines in the Pakistani state or society.”
Assistance from other institutions such as the World Bank and the Asian
Development Bank has been equally ineffective.
These stories of failure are nothing new. They have been repeated over the
years in numerous programs all over the developing world. The interesting
question is why.
Some of the reasons are familiar. Developing countries-often beset by
political instability, outmoded institutions, meager resources, and a host
of other woes-are desperate for money. (When, in a conversation with a
Pakistani official, I predicted the failure of the SAP, he replied that at
least it would bring in “foreign exchange for the national kitty.”) At the
same time, international lending organizations such as the World Bank are
under pressure to make loans; otherwise they are out of business. Some
baseline “tangible” results are expected when the project ends, but these
mainly take the form of documented capital outlays (schools built, computers
purchased, etc.) and published reports. There is little interest in
assessing whether the projects have actually had an impact on people’s
The development history of Pakistan, long before the first SAP, was full of
hastily assembled programs that lacked adequate support institutions or
other infrastructure. The legacies of this haphazard approach are
everywhere. Health centers cobbled together sit locked and empty-sometimes
because they lack staff and supplies, sometimes for reasons that aren’t
readily apparent. The situation in education is at least as dire. “Ghost”
schools, which show enrollment figures higher than the number of
malnourished, bedraggled students living in the whole village they
supposedly serve, are documented as major achievements.
The specialists who design the programs work for and are answerable to
distant development agencies. Most are narrowly trained technicians from
Europe or the United States who have very little understanding of the social
conditions and institutions in the country they are dealing with. At a
personal level, they bring with them something more destructive than
ignorance: a certain kind of palpable arrogance. They have been designated
“experts”: foreigners who represent high-profile donors and who command
exorbitant salaries. Most are white, which, given Pakistan’s colonial
experience, imbues them with a tincture of superiority in the minds of the
general public. White Europeans were, after all, the colonial “masters.”
Being human, these experts very quickly gain an exaggerated sense of their
own authority and a disinclination to entertain ideas divergent from their
own. Consequently, they end up using their sometimes considerable financial
decision-making power not to benefit the country they’re supposedly there to
serve, but in the interest of their own institutions or to protect their
Present in the country for a short period of time, they are focused on the
product-an impressive report, expenditures made-they signed up to deliver.
They favor technocratic “solutions.” Sickness is to be combated with
clinically skilled people, for example; to deal with illiteracy, it is
assumed, you need teachers and reading materials. The relationship between
problems and their social context is left unexamined. Grandiose, fuzzy, and
unrealistic plans that rely on capital outlays and numbers of people to be
trained are quickly drawn up with the representatives of the host
government, which participates happily-for this will bring in money-or
unhappily, because there is no other option. Most funding agencies work on a
short budget cycle, so even if some die-hard planner wants to, there is no
time to consider larger issues and long-term solutions.
Yet those who give aid and the governments that receive it have the feeling
they are “doing something” to respond to the nation’s ills. Most specialists
do their jobs to the best of their abilities. People with experience know
full well that most of the time they are just muddling through, trying to
meet deadlines. In the end, government officials, technical consultants, and
aid agencies all hope that “some” good comes out of the muddle. Alas, when
muddle goes in, muddle comes out, as we have seen in the years since that
afternoon in Mrs. S.’s tidy little office, where we witnessed that muddle
with our own eyes.
Mrs. S. started by telling us about the background of Pakistan’s nursing
system, which was inherited from British colonialists.
“We use the same curriculum that was used to train British nurses during
World War II,” she said with obvious pride.
“Surely it has been updated since then,” said Lucymemsahib jokingly.
“You really mean it has never been updated since then? Why not?” asked
Lucymemsahib, quite aghast.
“There was no need to,” replied Mrs. S. “Only recently, after all this
Alma-Ata business, there is pressure to change it,” she added, sounding as
if this were completely unnecessary.
That “business” was an international conference held in the city of
Alma-Ata, in what is present-day Kazakhstan, in 1978. Considered a watershed
event for the design of health delivery systems in developing countries, the
conference decreed that services based on the Western model were
inappropriate for these countries. Since most health problems in developing
countries were believed to be the result of environmental problems such as
poor sanitation and malnutrition, it was decided that they should be tackled
by making improvements in the environment. Any remaining medical needs could
be addressed by minimally trained local health workers.
The wisdom or folly of this policy and the tale of its selective
implementation are matters for another time. Most of the developing
countries, including Pakistan, signed on to the resulting Alma-Ata
Declaration, promising to reorient their programs according to a primary
health care (PHC) model introduced at the conference. Since there was little
discussion of how this was to be done, however, each institution in Pakistan
translated the model as it saw fit.
“To meet the needs of the PHC model, we are going to stress more community
medicine and family planning in the nursing curriculum. Nurses will be doing
all this along with their regular work,” said Mrs. S.
“Why?” asked Lucymemsahib. “Nursing is, as its name says, nursing. And
equally important. What hospital can function without good nurses?”
“That is true. But it is in the declaration. We have to do community
“But what about nursing?” insisted Lucymemsahib, clearly not happy about
nurses’ involvement in this community medicine business.
“What particular aspects of community medicine?” I asked, knowing full well
the many colors and constructions of this much-maligned term.
“Oh, just some things to do with the community,” offered the director
After completing a 24-month curriculum, including a practicum rotation in a
hospital, nurses take the examination administered by the Pakistan Nursing
Council. Once they pass, they are certified and registered by the council.
Sounds good. This means there are standards that can be monitored.
“But it does not matter,” our good Mrs. S. said, “whether they are certified
or not. A lot of organizations hire nurses without any certification and
registration. Especially the private hospitals and clinics. And since these
institutions pay a lot more money than does government service, the nurses
prefer to work for them rather than for the government. Many do not even
wait to complete the training program.”
“Do these organizations then train these people themselves?” asked
“Oh no, there is no need to train them. They can work.” At least Mrs. S. was
“What do you mean, there is no need?”
“Well, they do know the work.”
“What work do they do?” Lucymemsahib was genuinely confused.
“Nursing work,” responded our hostess calmly, adjusting some papers on her
“But nursing is a skilled profession. A nurse, to be effective, has to
perform certain tasks which are technical, and many times critical.”
Lucymemsahib looked at me, her face flushed and eyes shining with
indignation. She was a registered nurse herself. In Canada, nursing is a
highly skilled, well-organized, and respected profession.
“Ah, but you see, there is no rule which says that you are not allowed to
work as a nurse without certification,” Mrs. S. explained patiently. “And
practically speaking, even if there were, there is no way we can reprimand
them. There is no way to enforce this rule.”
“Can you not change the rules and put in regulations?” Lucymemsahib turned
again to Mrs. S.
“What rules?” asked the lady mildly.
“The rules regarding the employment of people who are not properly qualified
to do the job.”
“No, no, rules should not be changed, for this would lead to a lowering of
standards, and it is very important to maintain high standards.” Mrs. S.’s
voice rose with emotion. For all her life, she told us, she had fought to
adhere to standards “against all odds.”
“What standards are you talking about?” Lucymemsahib’s voice was also high.
“The standards of nursing, the noblest profession in the world. It must have
the highest standards in the world.” Mrs. S.’s voice cracked on the high
And, just as suddenly, both ladies stopped talking. Their faces were red and
they were out of breath.
Lucymemsahib’s worry was justified. Even today, one need only visit any
facility in the large cities to see what is going on. “Nurses,” whose only
claim to the title is their little starched uniform, are blundering through
people’s lives. I saw a nine-year-old boy die after a routine appendectomy
because a nurse did not know that she needed to give him a test dose before
administering penicillin, to check for allergic reaction. A hypertensive man
had a stroke because the nurse who was monitoring his blood pressure did not
think she had to alert the doctor when it became dangerously high. There are
nurses who do not know how to read a thermometer.
At the same time, nurses have thriving private practices in towns where they
are called “doctor.” They dispense medicines, suture wounds, treat ingrown
toenails, perform abortions. One enterprising young lady was doing
outpatient cataract removals in a small town just 50 miles from where we
sat. Her name came up again and again whenever the subject of private
medical care or palatial houses-the two go hand in hand in Pakistan, as in
other countries-was under discussion. She had done well enough to build a
mansion within two years of opening her “practice,” complete with marble
foyer and imported toilets, which, though completely unusable because of the
inadequate water supply, were nevertheless the cause of much envy.
“Why do employers hire unregistered nurses, when they know that these women
might not be adequately trained?” My friend was persistent.
“Because there is an acute shortage of nurses in the country, and no
clinician can work without nurses,” replied Mrs. S. This, too, was a fact,
consistently documented. “To date, 19,000 nurses are registered with the
council, and given the population, this is an extremely poor
nurse-to-population ratio. This means we have one nurse for 6,000 people. On
top of that we think that easily half of these 19,000 are out of the
country, and the other half are trying their best to get out too. As you can
see, there are just not enough nurses to meet the demand. That is why even
untrained girls are hired. That is why we need to train more nurses.”
(According to the World Health Organization, Pakistan had 48,446 registered
nurses in 2004-though there is no way to know how many of these nurses were
actually in the country-and the fact that health indicators have barely
budged shows this is mostly an improvement on paper.)
“This situation exists only in urban areas, does it not?” I asked, for
Pakistan is certainly more than its three large cities; almost 70 percent of
the population is rural, and rural-urban disparities are a major hurdle in
developing standard programs or uniform employment salaries, benefits, etc.
“Of course. What need is there for nurses in rural areas where there are no
hospitals? As it is, we do not have enough nurses for urban areas,” said
“Why do you then not increase the output? Surely in a country where there is
a shortage of jobs, this should be a very attractive option for women.”
Lucymemsahib was being logical, applying the law of supply and demand. But
this was Pakistan, and there were yet another 10 layers to the problem.
“This is easier said than done,” Mrs. S. replied, with a pursing of her
lips. “It is not easy to attract girls and women to go into the nursing
profession, especially if they come from good families.”
“What on earth do you mean!” Lucymemsahib was horrified. “Is it because of
poor salaries? Is the pay that low?”
“Oh, no, pay has nothing to do with it,” replied Mrs. S. “Girls prefer to go
into teaching, although that has still lower pay. It’s just that nursing is
not considered a . . . a decent profession.”
Lucymemsahib looked from me to Mrs. S. and back again, her mouth opening and
closing like a fish’s.
“But you are a nurse, aren’t you?” she said, once she got her breath back.
“Oh, no, no I am not.” Mrs. S. was quick to correct her. She was from the
federal bureaucracy, a civil servant. Down to the present day, no nurse has
served as the director of the Pakistan Nursing Council.
The institution of nursing in Pakistan is a strange hybrid. It is built on
the foundations of the health and medical system created by the British in
the 19th century to serve the colonial and local elite. Initially, nurses
came from Britain. Later, especially during World War II, nursing programs
were set up in local hospitals, and, as in Britain, women were recruited.
This was a challenge. Educated women from middle-class households, who had
some schooling, were reluctant to go into professions. Those that required
close contact with people, especially males who were not part of a woman’s
immediate family, were even less attractive. At the same time, Christian
religious missions were well established on the subcontinent, and they had
their own schools and hospitals. The missions also took in abandoned infants
and children, most of whom were the offspring of English men (often
soldiers) and local women. These Anglo-Indians, like the mestizos of Latin
America, were mostly the products of nonmarital unions and were shunned by
society. They were therefore prime candidates for conversion to
Christianity, and for less desirable jobs. Almost all Anglo-Indians on the
subcontinent are Christians. At first, most of those who went into nursing
were Anglo-Indian Christian girls who lacked other options. From the
beginning, nursing in Pakistan thus suffered a double handicap, and it is
still seen as an “inferior” profession.
“You have mentioned that nurses leave the country at the first opportunity.
Is that a major problem?” I restarted the conversation on a topic that
“Oh, yes! It is a terrible loss,” Mrs. S. said, with genuine feeling. “Our
own country desperately needs the manpower. But what can we do?”
“All governments can stop the qualified personnel from leaving the country,”
said Lucymemsahib. “The government can mandate this.” Poor Lucymemsahib! For
the life of her, she could not understand why it was so difficult for a
government to stem the exodus of its trained womanpower, especially since
the training was financed by taxpayers or other government-funded programs,
as in the case of nurses and physicians.
“All government servants who wish to leave the country need only obtain a No
Objection Certificate from the government, and they can go wherever they
like,” Mrs. S. told us. “Most of the time people are granted this
certificate. But it can be withheld in case of essential personnel.”
“Aha!” Lucymemsahib pounced on this opening. “Then the government can refuse
to give this document to people that it thinks are needed in the country.
And it is clear that nurses, being in short supply, are essential
“But why do it?” Mrs. S. asked patiently and sincerely. “As it is, there are
not enough jobs in the country to absorb all the qualified nurses. They go,
for they too have families to take care of.” She looked to me for
understanding. “They work for some years on short-term contracts, and after
they have made enough money to build a house, or educate a brother, or
collect a dowry for themselves or for a daughter, they come back again.” She
added, after a brief pause, “In fact, it is better to let them go.
Otherwise, they create trouble for us.”
The fact that international assistance pays for the training of new
personnel but not for salaries to employ them is a major and unresolved
problem in all rural health programs in Pakistan. Aid organizations assume
that trained workers are an asset to the government, and expect local health
service delivery systems to absorb them. In reality, local governments do
not have the institutional capacity to deploy, pay, and utilize the trained
work force. Hence, senior officials hope that trained personnel, who can be
demanding and vocal, will just go away. Their exodus, though contrary to the
objective of these programs, relieves the government of blame for not using
But because policymakers and development experts agree that skilled manpower
is essential for improved services, they continue to design and fund
training programs. Pakistan has been a recipient of aid for such programs
many times. International experts don’t try to figure out how the workers
turned out by these programs might be used. That is left to the host
governments. In unstable regimes, administrators-who are often political
appointees with little accountability and slim hope for long tenures in
their jobs-have neither an interest in doing this nor an inkling of how it
could be accomplished. Or their hands are tied because programs that have
been developed outside the country rigidly bind funding to specific
activities, even if they are of little use.
Unfortunately, most program evaluations, usually conducted in-house by the
donor organizations, rate the training programs as successes, since their
products are tangible and can be measured. The host country is happy because
the programs bring in lots of money. The local managers are happy because
they receive personal rewards-special remuneration, a vehicle, trips to
donor countries, and so on. Lending agencies, such as the World Bank, and
grant-giving agencies, such as the U.S. Agency for International
Development, are happy because they are able to disburse funds in time for
the next budget request.
“Oh, good,” said my companion, seeing some advantage even in this bizarre
situation. “Once these nurses come back, they are more experienced and thus
more valuable, so they can be hired at that time. At least the government
will have the trained manpower it can use.”
“Oh, no, no.” Mrs. S. almost recoiled at this suggestion. “Now they cannot
be hired at all. The government has placed a ban on re-employment of
returning nurses. Any nurse who has worked outside the country in her
private capacity cannot work for the government again.”
“But why not? They are more experienced. . .”
“Because,” and here Mrs. S. did a wonderful imitation of being hurt, “they
have rejected us in the first place. Now why should we accept them?”
Actually, the ban is not based on sentimentality alone. Government rules
forbid the hiring of anybody 35 or older in regular federal jobs. This, so
the explanation goes, is because a government employee can retire with full
benefits after 20 years of service. Older people will be more likely to
depart as soon as they are eligible, taking their experience with them and
drawing full benefits. Most nurses who return after spending some years out
of the country are nearing or past age 35, and thus are automatically
ineligible for federal employment.
Not enough nurses. Not enough jobs. Nurses working as “doctors.” Trained
nurses being encouraged to leave the country. Untrained and uncertified
“nurses” being recruited in sheer desperation by private hospitals. What a
strange and paradoxical situation! Yet there is no discussion of these
crucial issues. And new training programs are being developed, because there
is pressure from international organizations to include more women,
supposedly to meet the human resource shortage.
My companion sat shaking her head. Mrs. S. was starting to look restless.
She signaled to the attendant for tea. In a government office, a tea break
can become a project unto itself.
“The problem with women,” Mrs. S. volunteered conversationally, again
adjusting the dupatta delicately on her hair as the tea service was laid
out, “is that they all want to get married.” Quite a problem, and one the
world over. “So eventually they must leave the profession to take care of
their husbands and children.”
We let this pass, and raised another possible solution to the “problem” with
women: training more male nurses. As the primary wage earners, they would
not be compelled to leave once they married, and they could tend to the male
patients, making it easier to attract women to the profession.
“Not a good idea,” according to Mrs. S. And why not?
“Because men are very unreliable. As students, they will agitate the girls,”
she continued in the same conversational mode, oblivious to the effect of
her remark on her audience. “If they are in classes together, they will
induce them to strike on petty matters.”
“But the girls are under no obligation to do their bidding,” Lucymemsahib
“Yes, but the poor girls have no choice but to follow the boys. It is
natural for them to do so. By themselves, girls never cause any problems.
They quietly do what they are told or get married and go away.” Mrs. S.
warmed to her subject. “Look what is happening in Liaquat National Hospital,
Karachi.” Liaquat hospital is a major training institution for nurses, one
of the few in the country that prepare male nurses. About a third of each
entering class was male (as is still the case today). During the weeks
before our visit to Mrs. S., the nursing students at Liaquat had gone on
strike, demanding better living conditions, apparently at the instigation of
“All because of these boys!” Mrs. S. continued. “So many headaches these
boys are causing us.” She struck her forehead with the palm of her right
hand in the traditional gesture of frustration, causing the dupatta to flop
off her hair. She hastily retrieved it. “And the girls are not listening to
us either. They are naturally listening to the boys. Stupid things!” She
shook her head in indignation.
Lucymemsahib looked at Mrs. S. as if she had come from another planet.
Thankfully, the tea arrived at this point, and we fell to it with gusto,
under Mr. Jinnah’s enigmatic smile from his perch on the wall. Mrs. S. very
generously ordered her attendant to run out for some mint chutney to go with
the samosas, which were really out of this world.