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Dr. Shabnum Sarfraz is Senior Advisor for Health Systems and Policy Research at P2Impact Associates and Member Social Sector & Devolution, Planning Commission, Government of Pakistan, Islamabad. She is one of the Inaugural 2019 Jane Jie Sun Women in Global Health LEAD Fellows at Harvard University where she conducted research into barriers to women in health career advancement in Pakistan. Her work focuses on health systems management and policy reforms and she has managed large-scale, high-impact health projects while working with the government of Pakistan and partners such as DFID, USAID, and WHO. Shabnum holds a degree in medicine from Pakistan and an MBA from the University of Surrey.
First and foremost, are there any key leadership messages you want to get out to our readership?
I work for the Planning Commission at the Government of Pakistan and we are really having to think outside the box in dealing with COVID-19, but, somehow, this pandemic has provided us with an opportunity to shift the focus to where the priorities should have been all along. For example, I look after the education portfolio at the Planning Commission at the national level. Before the pandemic, we had been asked to be innovative in our approach, but there was little innovation in the way we were running things. When COVID-19 hit and the educational institutions got closed, we were worried about all the children out of school and the disruption to their education. However, what we saw was all the interventions brought in to address this, like tele-education. We have a television channel now in Pakistan, ‘Teleschool’,1 which children are ‘attending’ because not all schools and children have online access. It makes me think how great this is for addressing the digital divide. How can we better use technology for bringing in innovative modes of education? We are not only enhancing access, but also equity of access, as now this channel is being used by those students who are no longer going to school as well as those that have never been able to go to school.
In health, it is an opportunity for us to enhance our reach and provide access to quality consultations and diagnostics. For example, X-rays or ultrasounds can be done and then a radiologist or senior ultrasonographer can read them remotely. There have been small pilots, but now, with this disruption, this sort of innovation can help provide continuity of services. There are incredible opportunities for innovation in government planning. I see a lot of opportunities for leaders to look beyond merely addressing the crisis but looking at sustainable solutions.
Tell us a little bit about your leadership role and how it is changing as a result of the pandemic?
I work for the Government of Pakistan Planning Commission, which is headed by the Prime Minister, and I look after the social sector portfolio at the national level. At the Planning Commission, we agree our annual budget, receive demands from different sectors, evaluate, allocate budgets and prepare annual development plans. In low-income countries like our own, we know that the social sector budgets are never as much as they should be. Though leaders want to work for vulnerable populations and to strengthen systems, the limited funds are a big barrier. So, now with COVID-19, suddenly everything is reprioritised, everything needs restructuring and also the need for evidence has become much more important. At the national level, I am leading the development of the national action plan for COVID-19 and I am working with UN partners who are supporting the Planning Commission and undertaking a comprehensive socioeconomic impact assessment. My teams at the Planning Commission are working closely with the different ministries because the Planning Commission has a unique convening power to bring together all sectors, the provinces and the provincial departments, as well as the private sector and the NGOs. This is important as no other department can do this and normally work to their own mandates. COVID-19 is not limited to one sector; it has disrupted and had an impact on everything, directly or indirectly.
The most important aspect is keeping vulnerable populations at the core while we are designing and developing our plans, because they are the ones who are most at risk of impact ofCOVID-19. For any intervention, any activity, we are encouraging the sponsoring agencies to look at it from the lens of vulnerable populations with indicators identified so that when we roll these out, we are able to evaluate to ensure we are reaching out to these groups. For the first time, we are trying to implement a monitoring and evaluation framework alongside this national action plan so that, when we are doing our monthly and quarterly reviews, if we have these specific indicators around the vulnerable and most-at-risk populations for any of the interventions, we will have the data to track progress. I feel that this is going to help us in making our investments in the right places.
What events in your past experience are most informing your leadership in this pandemic?
My recent experience of being at Harvard as a Global Health LEAD fellow has been phenomenal because we do not have many women leaders at policy level in Pakistan. I am very conscious of the responsibility that I hold, being the voice for so many of those that are more impacted than our male counterparts. For example, 70% of the global health workforce is female; in Pakistan, it is about 77%, in nursing over 90% are females, and 60% of the rural populations only ever see a lady health worker for their health needs. But, there is a lack of females sitting at the policy tables, designing interventions or evaluating the policies. I feel it is really important, when we have these high proportions of females working on the front line, that we look at appropriate workforce and management issues. We already have a high turnover of female doctors in the country and, if we do not bring in policies, we risk losing more of them when we cannot afford to as we already have a critical shortage. With some of the things that have been disrupted due to COVID-19, such as school closures, it is putting these women under a lot of stress, juggling work with childcare, and so on, and we do not know how long it is going to last. Now, with the lockdown, there is no public transport, so having a pick and drop service, particularly for night shifts, is important. These may seem like small things, but, if you are not conscious of these issues, you would end up losing key staff. Fifty per cent of female medical graduates do not go on to pursue a medical career as the environment is not conducive for females. As a leader, I would think that this is the time and the opportunity and I would want to make full use of it, not only for saving lives, which is what we are all focusing on, but to ensure that whatever we do, we take a sustainable perspective that also revives the economy.
What are you finding the biggest challenges?
I was listening to a webinar by Leonard Marcus2; he teaches crisis in leadership at the Harvard Kennedy School. One thing he said, I just felt very deeply connected with: this crisis is very unique. It is unique in a way because every leader and every person is going through a personal crisis at the same time as trying to deal with the bigger picture. So, things are the same for everyone; we are all impacted but we know for some less, for some more. Looking at the longer term implications, I think it is very challenging for everybody, because you have an inner battle, and you have an outer battle too, and yet you have to manage. So, I think that is something which is unique to this crisis and it is making it very, very challenging for all leaders to get through.
Any particular surprises?
I have been working with the government for almost 5 years now and working on huge documents for institutional strengthening and how we can build capacity and get structures in place. The time frame in our minds was 2–3 years and we were gradually working with all stakeholders and through formal routes. Then, suddenly, when this epidemic started, we started working very informally and, after 4 weeks, I realised that we had done all those things informally that we had been planning to do very institutionally. There were people who reached out and volunteered to work with us and we quickly formed collaborations. There were universities helping us with the evidence and analysis, for example. We had thought of this before for building institutional capacity, but it just evolved in a very informal way. Again, I felt there were things that we had advocated for so long: strengthening our disease surveillance systems, bringing in communicable disease control legislation; there was little appetite for that before, because there was not an understanding of the importance of these issues which really required investment in the long term. Suddenly, these things have taken high priority—things that I had felt deeply connected with to build that resilience within our systems. I feel that this is an opportunity as people are receptive, people recognise that they need to build these systems. This is the time for us to push for these things, the public health systems especially which were not getting the due recognition, community mobilisation, the WASH3 interventions. These are the things all public health professionals wanted to hear, and now everybody is asking for them which is a pleasant thing to see—things going in the right direction—the way it should have been.
Are you seeing any behaviours from colleagues that encourage or inspire you?
I think it is great to see some very positive actions despite so much gloom. Positives coming into the limelight which we had been wanting to see for a very long time but were never getting prioritised. This may be an opportunity for us to put the house in order. There is dialogue to understand which sectors are less effective and how we should be making investments for revival. IT and other industries could really take the lead and we are making plans to do so. I think I like that sentiment of positive out of despair because that gives you a lot of hope that down this dark alley there is going to be a much more equal Pakistan that we had aspired for. A chance to work on our policies, our interventions, our plans and an opportunity to restructure and reprioritise.
How are you maintaining kindness and compassion?
I think I try to. I am on a number of charity boards and check in on the weekends or the late evenings. It is heartening to see that everybody has stepped up, no matter how small their work was or how large, and I do try and work with them technically, and I try to link them up with my networks to help enhance reach.
I have reminded myself and colleagues to understand that everybody is going through a crisis and that this is not the time to judge anyone. Just step back and think that people are going through a lot. So, if you can have this as a screen before interpreting what somebody has said or done, it helps. There are a lot of mental health issues at every level. Even at home, for example, one of my children is not coming out of their room. We need to be conscious of just keeping an eye on each other, that things vary day by day and there is a cycle of feelings.
Are there any readings that you find helpful for inspiration and support that you would recommend to others?
I try to be diverse because I am inclined to review a lot of work which the Harvard colleagues are putting out. There is work on women’s initiatives from the Business School and it is interesting to note how women are going to be affected at the workplace and, also, how this recession is going to hit them much worse than our male counterparts. I try to follow the work of the medical school, especially the webinars for the different perspectives that they bring from epidemiologists as well as social scientists. Ashish Jha4 is somebody that I regularly follow, and he is with the Global Health Institute. I am also in touch with CDC China as part of the International Association of National Public Health Institutes and they are holding regular webinars which I find very informative; they have got a website as well where they release updates. There are lots of lessons to learn from such countries, including China. We may not be able to do all of what they did, but at least some of it, and to learn what did not work for them so that we are conscious of those things.
What are you looking for from your leaders?
I would look to the media especially at this time. People have time to reflect, people are receptive and I feel the media can play a very big role in our country. This is the time to reinforce some behaviours and not talk of differences, but for a unified approach. From our leaders, I would certainly want them to focus on not criticising, as it is a global pandemic and it requires a global response and even at a national level it is a national epidemic. We all need to be together on this. I remember one of my previous bosses once said to me, “Whatever decisions we take are based on the information that we had at that point, so they may work out or they may not work out.” It is important that we do not lay blame for things that do not work out because many of the things we try may not work out. But taking a national perspective and taking everybody along is very important at this point in time rather than creating divides; that is not going to work out for any country, really.
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RA is Knowledge Mobilisation Lead, and supported by, the National Institute for Health Research Health Protection Research Unit (NIHR HPRU) in Healthcare Associated Infections and Antimicrobial Resistance at Imperial College London in partnership with Public Health England (PHE) and affiliated with the NIHR HPRU Modelling and Health Economics, and the NIHR HPRU Respiratory Infections. RA gratefully acknowledges the support of ESRC as part of the Antimicrobial Cross Council initiative supported by the seven UK research councils, and also the support of the Global Challenges Research Fund.
Author note Interview conducted by RA on 10 May 2020 behalf of BMJ Leader.
Contributors RA and Ms Sara Yadav edited the transcript.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests None declared.
Provenance and peer review Not commissioned; internally peer reviewed.