Applying Urban Thinking to Islamabad

Islamabad is beautiful and idyllic. It is rightly considered one of the most beautiful cities in the world – one that its residents justifiably pride in . So it may come as a bitter pill but the sooner we talk of these issues, the better. For Islamabad, the designed city. was never designed to be a city or to house the over million people that it is now home to.

Cities drive prosperity by bringing people and opportunities together with dense construction and good transport. Thus, successful cities are tall and well-connected while managing the problems of density with services (i.e. sanitation, transport) to promote citizens’ well-being, health and productivity. Islamabad is a 50 year old “designed” city whose safety and suburban beauty make it desirable. However, its design ignored key principles of urbanisation or its future growth. This has come to hurt it and its problems are only piling.

Islamabad is a large city that is spread over 900 square kilometres but has a population of merely 1.9 million. Compare that with the megapolis Karachi that is home to 24 million people but is spread over 1360 square kilometres. That means Islamabad has 2,100 people per square kilometres compared to 17,650 in Karachi, around 25,000 for Shanghai and 46,000 for either Kolkata or Mumbai.

Its short buildings (rarely above 12 meters due to height limit regulations), limited space for new development and in-migration have caused property prices to skyrocket. In fact Islamabad’s property values are among the 20 highest worldwide. Over 90% businesses operate in residential areas, further straining residential stock while causing traffic problems; as commercial real estate to accommodate these is simply unavailable. Recent ill informed campaigns to expels businesses have been fortunately thwarted. One can only imagine the effects of successfully pushing out all businesses to the few commercial areas had been. Very likely the rents would have increased by 4-5 fold, meaning that the average small office that now pays 100,000 or so in rent would be paying around 0.5 million a month. Wonder how many businesses would have survived or how viable would the city have been after losing nearly all of private sector service related employment.

Although idyllic, Islamabad’s services are sporadic and expensive. Electricity, natural gas and electricity are supplied discontinuously for few to several hours daily. Rolling electricity blackouts, once unheard of in Islamabad, now happen for 6-8 hours during peak summer. We are so used to such blackouts for water that we think it normal for water to be supplied for only half to one hour a day. Much of this lack of quality of service relate to how they are priced. All pricing of services is central, with no connection to their actual usage/ availability. Erratic supplies lead to additional costs for storage i.e. water tanks and UPS and use-insensitive pricing leads to overuse of water and electricity when they are available, which further aggravates shortages.

Municipal services cost over Rs. 125,000 per household annually (although only a few thousand of these are directly charged to customers, the rest come from budgetary allocations by the federal government and although we all pay for them, its through indirect taxation and generally invisible), excluding the costs of police, infrastructure and the land transferred to city employees. More importantly the various agencies that manage the city don’t answer to citizenry. Political representation of Islamabad is via the entire National Assembly rather than dedicated members. One has heard of the old axiom: when many are responsible for something, no one is responsible for it.

Recently initiated public transport, connects few areas; requiring nearly all 500,000 children and employees to commute to school and work in private vehicles. This excercise is repeated twice a day. The resulting traffic jams are aggravated by bottlenecked roads, roadblocks and traffic lights that malfunction during peak hours. Just as an example, if all commuters wasted just 10 extra minutes of their time each way, that adds up to 5700 years of time wasted. Roughly equal to 89 lifetimes. Each year. Add to this the costs of wasted fuel while idling, that comes to around Rs. 21 billion a year. All because we choose to ignore how modern cities manage their transport and traffic.

Islamabad can grow into a model city provided its growth is re-conceptualised with services that answer to citizens through political representation, use competition to manage supplies and costs of civic amenity, relax laws on construction height and expand its public transport system. In these it can learn from the Singapore, London and New York.

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The Doctors’ Conundrum

Recently I had a discussion with some young doctors who were very upset that their salaries were too low and felt rather strongly that the government owed them to increase their salaries. Ironically all of them had graduated from a public sector university which meant that they had received a Rs. 2+ million education for nearly nothing at all. Lets be fair, if I were in their shoes, I too would demand higher salaries and guaranteed jobs.After all they see everyone else in the society looking for government privilige as the way to make it in the society. But that is not how the world works.

Although there aren’t good data on how many healthcare providers work in Pakistan, the best estimates suggest that perhaps there are around 300,000 healthcare providers (around 1.6/ 1000 population) of which around a third are doctors. Doctors and doctor groups often cite the WHO which recommends that there should be at least 2.2 healthcare providers per 1000 population. The government obviously supports this argument since it subsidises the education of over 6000 new doctors each year. In fact more than 12000 new doctors are educated each year, slightly more in the public sector (for nearly free) than in the private sector.

This is where it gets really interesting. There are only 130,000 doctors currently registered with the Pakistan Medical and Dental Council. This registeration is mandatory for all doctors to be allowed to practice or receive the mandatory “house job” training. If we have been producing 12,000 doctors annually for 50+ years, even accounting for death and retirement, there should be at least 300-400,000 on PMDC registers. Even those who proceed abroad for education or migration must surely have done their house job training and hence must have registered with the PMDC. And yet there are only 130,000. This suggests that the vast majority of doctors who start their medical education never intended to practice in Pakistan and don’t even bother to do house jobs or register with the PMDC. To me this suggests that most of the medical students understand that their prospects in Pakistan’s job market are unacceptable and never even try to take their chances with it.

So what happens to those doctors who do practice in Pakistan. In our own research, those that practice in extremely poor communities such as urban slums and the rare few that work in rural areas, do so for very low rates. In one study in Rawalpindi and Tando Allah Yar districts, the average doctor saw 16 patients a day and charged Rs. 65 if they only gave pills and around Rs. 125 if they gave injections. Even specialists in big cities work very hard for their seemingly high incomes. Most of my surgeon friends that earn close to Rs. 900,000 to a million a month, work close to 90 hours a week. This comes to around Rs. 2,500 per hour. Professionals with similar length of training and experience that work in the corporate sector, earn at least 2-3 times more than that.

These factors combine to confirm that there is a glut of doctors in Pakistan, i.e. there are too many of us and Pakistan’s current healthcare markets can’t absorb all of us. Young doctors know this and many don’t even test the markets. More senior ones do and sometimes earn a good living but at the expense of tremendous working hours. It is not surprising then, that the most doctors I meet are dissatisfied.

One must ask, why then is the government producing so many doctors when there is a glut. Surely the argument that we need them in rural areas has worn thin. No one who has dedicated 16+ years of their lives on receiving an education and more years of professional training wants to work where basic amenities such good schools, social life and a decent income are unavailable. We have not found a solution for rural placement, producing doctors in glut is surely not the answer. A better option to Pakistan’s very skewed healthcare provider mix is to concentrate on producing more mid-level providers who feel more comfortable in rural or remote placement and stop the subsidy – i.e. free public sector medical education – to produce more doctors.

Since writing this, I found the following oped from 2013: The Doctor Glut by Rafia Zakaria, Dawn 19 July 2013

Independence Day 69 – Thanks for Our Home

Yesterday was Pakistan’s 69th independence day. Some celeberated exuberantly, while others remembered the ongoing sorrows. However, in the balance there was more cheer on the street than in recent years. And why not. Our independence day should be celebrated, if not for any other reason than the fact that we are free; for people without a land have wretched lives. Unhomed are never welcome anywhere.

That there were more people out in the streets than in recent years is good. Recent years have seen ordinary citizens abdicate public spaces to those who kill, terrorise or loot. For that reason alone it is good that so many Pakistanis felt safe enough to start reclaiming these spaces. It would be even better to have more places and activities where people can celebrate. But even when there are such few outlets for their joy, people turned out, claiming Pakistan as their own.

I see this as a slow and subtle turning point. Pakistan has not been easy for its citizens. Even today, a woman dies every half hour while giving birth and over half of our children and mothers are malnourished. Fewer than half the children study beyond secondary level and even when they do, they can’t read or write at that level. Nearly half of the population lives below the poverty line. 68 years later, this is not what nearly 2 million of our ancestors gave up their lives to achieve. They would want more prosperity for their children. So one may ask where is the turning point.

Slowly, things are improving. One sees the prosperity in the cities. The middle class has expanded. The GDP has more than doubled in the past decade. Indicators for development, health and education have improved albeit slowly. One felt that much that could have been possible in the past decade was squandered while the state played the militant game. This year, it appears that this game may be winding or at least tempering down. Any way, with a marked reduction in terrorist attacks on civilians and in public places this year, the change is noticeable and people are feeling a sense of safety.

Hopefully this will continue. People will continue to reclaim public places back from the militants and terrorists. The expressions of celebrations will transform from these forays into public spaces and flag waving to more constructive “owning” of the country. But this will take some time. People still have to feel that the country is their’s because it benefits them. Not a place where they pay all kinds of taxes while they also take care of their families and loved ones. All that will take time and will require continued stability, safety and some measure of economic independence. People need to continue to feel that their efforts can consistently give them returns and not be arbitrarily taken away from them at someone powerful’s whim. This feeling is still too strong and with good reasons. The state and its government remain whimsical and arbitrary. But even that is slowing down as people have learnt to protest and make it heard. Hopefully this trend grows, driven by increasing autonomy and economic power of the people and the resultant ability to be heard by their leaders.

Still the road is long. But in the meantime, let us be thankful. We have a land that is ours where all this can play out. Onwards to another decade. May its end see us better off than now, by far.

Why Politicians Don’t Smile and the Political Crisis in Lahore and Islamabad

I never realised it until I worked closely with them, politicians in Pakistan dont smile much. The more senior they are the less they smile. Of course this is completely opposite of what you see in the US or UK. Smiling is a gesture saying: “I am going to be nice to you”. Politicians in the US or UK thrive at the pleasure of their voters. They must behave nicely to their constituents. A US politician who can’t kiss a few babies on the campaign trail should probably just not contest the election. So what’s different with Pakistani politicians. Their power comes from who they can push or extract favours from, that is what they are elected for. Helping voters and their approval means little. If you are in the business of pushing people, you dont smile, you scowl. Pakistani senior politicians are somber people, they scowl a lot.

We are seeing this in the current crisis playing out in Islamabad and Lahore. Mian Nawaz Sharif, the legally elected Prime Minister with over 50% of seats in the National Assembly is running scared against the onslaught of Imran Khan who has fewer than 10% of the seats and Tahir ul Qadri who has absolutely none. Both want to topple his government and dream of becoming kings. 

Imran Khan feels that electoral rigging in May 2013 elections cost him Prime Ministership. Why he is turning to street protests 15 months later is beyond me. Never mind that FAFEN felt that although there were malpractices, all parties did them and they would not changed very many seats. Surely not the 120 more seas that PTI needed to form government. The courts agree with this conclusion. So now Imran Khan has taken to street intimidation (ironically their partners in KPK government are Jamat-i-Islami, the seldom elected masters of street intimidation). There is an implicit understanding that PTI and its leaders are demonstrating: People and their will means little, when you want political power, do it by force. 

Tahir ul Qadri is doing the same. He never contested elections. He even tried to stop them last year with his week long siege of Islamabad (where he got the 50+ crore rupees it must have taken to do that is beyond my understanding). He too is using his street power to topple the legally elected government of Pakistan and has explicitly expressed this aim in public. 

The leader of the nation, Nawaz Sharif, also has little confidence in the will of the people. Ideally when faced with intimidation from IK and TUQ, he should have come out and said: “the right to protest is constitutional and we respect that. Please use these designated public spaces legally to do that. We will listen and talk with you. But you can not hold entire cities hostage. Your protest must only happen on holidays. Dont stop the businesses because we are a poor nation and cant afford the roughly 20 billion rupees that this stoppage will cost the residents of Lahore and Islamabad for each day that you hold your dharna”. But this is not what he did. His minions used heavyhanded and sly approaches such as closing off petrol pumps and commandeering cargo containers (wonder if they paid for their use) and blocking roads and adding to the misery of the people. They were faced with illegal protest and feel reluctant to use legal force of the state to restrain it speaks volumes of their belief in the system. They could have relied on the voters that brought them into office and said: we are faced with this challenge, help us sort through it. It may have been difficult and perhaps even uncertain but that would have brought the voters into the decision making centre and would have strengthened the government. But that didnt happen because like IK and TUQ, NS also does not believe that voters have any say in all of this. They too resorted to what they understand politics to be: overt and covert weilding of power. After all, that is what politics means in Pakistan. Its not about pleasing the voters or making allies.