Bulletin of the World Health Organization

Choked pipes: reforming Pakistan’s mixed health system


Publisher: Oxford University Press, 2010;

ISBN-13: 978-0195479690; 336 pages; 750 Pakistani rupees.

Choked pipes presents an in-depth case study of Pakistan’s health system, identifying systemic bottlenecks and proposing areas for reforms. It serves two main purposes: (i) it contributes to the as-yet-limited evidence base on comparative organization and functioning of health systems in low- and middle-income countries; and (ii) it provides a systems analysis linked to a multi-dimensional reform agenda.

The book refocuses attention on health systems as the lynch-pin that shapes progress on health indicators. As current development dialogue centres on the achievement of Millennium Development Goals and poverty reduction targets, this book provides a timely spotlight on the investment needed to develop effective, transparent and pro-poor health systems.

The book opens by outlining the “mixed” public and private sector configuration of Pakistan’s heath-care system. It explains this design by the colonial origin of the public sector and unharnessed growth of the private sector. The main body of the book then provides a detailed description of the health system and its operational realities. Discussion is structured around World Health Organization domains of health policy, governance, financing, service delivery, human resource, medicine and technology, and health information systems. The most critical problem is institutional decay due to rigid bureaucracies, staff malpractice and low government priority social sector reform. This blunts the public system’s performance and limits its ability for “out-of-the-box” responses for creatively dealing with the growing private sector and responding to intra-sectoral issues. The last chapters are the analytical ones providing a framework for reform. This perspective is refreshingly based on a wider interpretation of health as a broad social policy vision and a universal right rather than the more commonly applied interpretation of health as a commodity.

The book is well articulated and candidly sets out issues constraining health system outcomes. Although drawn from the Pakistani setting, this book will be relevant to other low- and middle-income countries. It could have further benefited from the use of primary research and case studies to illustrate some of the key discussion points and to delve into reasons for failure of projects for health systems improvement.

Nishtar’s book has something to offer for both the local and global audience. To the local audience, it argues for a radical overhaul of Pakistan’s poorly performing health systems – hence the analogy to “choked pipes” – and charts a pathway for reform. Of relevance to the global audience is the analytical linking of health systems improvements to pro-poor macro-economic reforms, institutional re-engineering and adequate resourcing of the public sector, strategic use of technology and creative harnessing of the private sector.

Shehla Zaidi b

b. Aga Khan University, Stadium Road (PO Box 3500), Karachi, Sindh, 74800, Pakistan (e-mail: shehla.zaidi@aku.edu).

Bulletin of the World Health Organization 2010;88:876-876. doi: 10.2471/BLT.10.079285