In 2011, 352 people died of dengue fever in the Pakistani state of Punjab. The following year, no one died, and deaths have been minimal since then.
The difference was made not by some groundbreaking treatment (there is none), but by Punjab state’s innovative use of simple technology; something Jim Yong Kim, the head of the World Bank, recently named as one of the most momentous initiatives happening in the business of government.
Similar initiatives, underpinned by consistent political will, have also contributed to an astonishing drop in incidences of polio – after four decades of failed vaccination programmes – and led to more than ten thousand disciplinary actions being taken against corrupt public officials.
The man behind it, Dr Umar Saif, was a career academic until 2011. He studied and taught at Cambridge and MIT before becoming Vice-Chancellor of Punjab’s IT University. While on sabbatical, and tired of running little projects that never went anywhere, he took a post as head of Punjab’s IT board, intending to stay for a few months.
Just as he started work, the annual dengue outbreak was becoming a pandemic. More than 20,000 people were confirmed as having been infected. Two days after Saif started work, the Punjab’s chief minister, Shehbaz Sharif, instituted daily 6am crisis meetings, at which he called his heads of department into a room and asked them what they were doing about it.
Dengue is spread by mosquitoes and the chief means of halting a pandemic is to spray insecticide into the air, and pour it into the standing water where larvae flourish, such as puddles, ponds, buckets, bins and even old tyres. The problem, however, is that this relies on the state’s employees doing their jobs properly, something that in Punjab has often demonstrably not been the case.
During one crisis meeting, a head of department was showing powerpoint pictures of the work his subordinates were doing, when Chief Minister Sharif interrupted. As Saif recounts: ‘The chief minister said, “This picture doesn’t have a time stamp. How could I be sure that you’re not recycling pictures from some previous work and are just fooling me into thinking your department has actually done this work?”
‘That’s when he pointed to me and said, “Can you develop a system that’ll enable me to verify where the work was done, who did it and when?”’
Part I: The overnight honesty app
The software they wrote ‘essentially overnight’ was for Android smartphones. Instead of using digital cameras to document their activities, the state’s employees were given cheap phones, which digitally stamped each picture with a time and a GPS location. To date, 3.5million pictures have been logged.
As the system was shown to work, prompting employees to carry out their tasks more diligently, it was both scaled up and made more sophisticated. The government employees were also asked to geo-tag sightings of the dengue-bearing mosquito, aedes aegypti, and the houses of confirmed patients. The larvae reports now run into the hundreds of thousands; the patient reports into the thousands.
That allowed Saif, who gave up his university tenure to run the programme, to create an early-warning system for future outbreaks. Now, when a high concentration of patients is found in a particular neighbourhood, the local authorities can sweep the area and often identify the body of water responsible. The data are emailed daily at 3pm to all concerned districts.
Nonetheless, the programme still depends on the actions of local authorities. This year, there has been a big outbreak in the city of Rawalpindi, with cases again numbering in the low thousands. More than ten people have died. This is something Saif attributes to a lapse in the use of the early-warning system, saying, ‘They didn’t use the system until very late in the season when the outbreak had already spread.’
It’s not just for dengue fever
Punjab is now also deploying the tracking concept in other fields, notably polio vaccination, against which the country’s results have, if anything, been even more striking. Last year, a bad year, the World Health Organisation counted 306 of the 359 worldwide polio cases as being in Pakistan. The only other country where it is classified as endemic is Afghanistan.
Polio persists in Pakistan even though the distribution of the vaccine began in 1974. One of the primary causes was, again, the failure of vaccinators to do their jobs properly, and indeed much of the disease burden came from failed vaccination programmes. This year, Dr Saif’s team introduced another geo-tagging app, with which vaccinators have to check-in, as on Foursquare. Last October, when the programme began, Dr Saif says their attendance was at 21%. Now it is over 90% and ‘We have been able to declare city after city polio free.’
In Pakistan as a whole, cases have dropped by 85% on last year’s numbers, and the country now aims to eradicate the disease next year.
We saw an opportunity and we took that opportunity
This is not only down to technology. In the northwest of the country, bordering Afghanistan, there has been considerable resistance to vaccination, after revelations in 2011 that the CIA had covertly organised a hepatitis vaccination campaign to try to get the DNA of Osama bin Laden. Vaccination teams actually came under attack as a result and the government lists 84 deaths among them.
Last year, however, the Pakistani Army pushed forward into North Waziristan, displacing militants who had made the area largely off-limits to vaccination teams. When more than 100,000 families were evacuated from the area, they were stopped at checkpoints and vaccinated.
Moreover, they were given free SIM cards for their smartphones. Health officials controversially used the SIM cards, unbeknownst to their owners, to track the families’ locations. When large clusters of people from North Waziristan settled in other parts of the country, vaccinators were again dispatched.
Safdar Rana, head of Pakistan’s Program on Immunization, has defended the move by saying, ‘We saw an opportunity, and we took that opportunity. We will continue to look for opportunities to finish this job.’
Part II: User reviews for government
The innovations mentioned so far are essentially means of government checking that its workers are doing their jobs properly. The largest application of these ideas, however – and indeed their origin – has been in having the checking up done by the public. It has reached millions.
Eight years ago, the head of the administration in the Punjabi district of Jhang, Zubair Bhatti realised that, ‘I had 20,000 people reporting to me and no idea what they were doing, which is usual in the West as well, but more usual here.’ After complaints of petty corruption – of baksheesh, which he describes as a ‘cesspool’ – he started to randomly ring up people who had just used the property registration office and ask whether they had paid a bribe.
They were astonished. Jhang has around three million inhabitants and here were people – whose experiences of government were of opacity, unhelpfulness and sometimes petty extortion – being personally called by the head of the administration, to ask whether they had been given what was their right.
Even in the West, government doesn’t reach out to citizens
His crucial insight was that no one would ever bother to ring up a government hotline and complain about quotidian corruption, nor indeed about anything except the most egregious dissatisfaction with government services.
Bhatti says, ‘Now that I’ve thought about it that much, we were essentially trying to mimic private sector feedback. You go to a hotel, where you come and then they send you an email asking about the quality of the service. The public sector just doesn’t do it. It always has these complaint hotlines. Even in the West, it doesn’t reach out to citizens the way the private sector does every day.
‘This is my big frustration of the last eight years of speaking about this idea: every time you talk about it, they say, “Oh, we have a hotline.” And a hotline is different from pro-active feedback. What we’re trying to implement is a kind of permanent survey of the quality of service.’
Bhatti now works for the World Bank on implementing this system on a national level and elsewhere, notably in Albania, which between March and June this year contacted 1% of the population. He seems both tired of being asked about it and deeply reluctant to accept any credit for a bright idea. He emphasises that people in the public sector are constantly having bright ideas; the proof is in the implementation.
Tackling corruption one citizen call at a time
In Punjab, this idea has been driven on by Chief Minister Sharif and, specifically, by Dr Saif, as it has been refined, automated and increased in scale. Now, after citizens’ phone numbers are collected, they are robo-called with a recording of the Chief Minister’s voice asking them to reply to a text message they are about to receive. This asks an objective yes/no question, such as: were you asked to pay a bribe? Did you receive the medicines to which you were entitled? Did the police arrive within 30 minutes of your calling them?
As Dr Saif says, ‘We don’t seek their general impression. We want to ask about parameters we’re interested in. We don’t ask whether they were satisfied with what the police did, because that’s a complicated business. So the only question is, did the police show up within 30 minutes or not?’
The latest figures show that in the past two and a half years, 8.6million people have been called, 1.12million have responded and 178,000 have reported corruption. From those complaints, the government has initiated 11,160 disciplinary actions against officials.
You could feel the change. No one asked for a bribe
The aim is not to catch individuals or redress individual grievances, but to improve services as a whole or, as Bhatti puts it, to ‘help people who haven’t even complained to you’. Monitoring happens on a macro-level, comparing district levels of corruption to one another and acting where it is higher.
More important than prosecution is prevention. Officials who know their activities may be reported are less likely to ask for bribes in the first place.
Nevertheless, it remains almost impossible to measure rates of corruption, or a reduction in them. Saif compares eradicating graft to trying to ‘boil the ocean’. Both he and Bhatti believe that it is decreasing despite its cultural entrenchment, and there is anecdotal evidence to support that. One of the responses from Albania reads: ‘This time you could feel the change. No one asked for a bribe.’ The size of the bribes themselves may also be decreased as officials become more nervous.
There are types of corruption against which this initiative is powerless, such as when officials collude with members of the public or when graft is far higher up the hierarchy.
But one of its most important effects had been to improve trust in the government, and counter the impression that corruption is endemic and ineradicable. An as yet unpublished report commissioned in the Punjab shows that citizens who remembered having been called by the state were more likely to say they thought that corruption had decreased. The mere fact of pro-active engagement from the state improved their satisfaction with its services.
As Bhatti puts it, ‘A lot of the feedback we get in the Punjab, in Albania, in the federal government [of Pakistan] is: “Thank you for asking.” Sometimes they say, “We got good service, thank you,” and sometimes they say, “We paid money, but still we thank you for asking.”’
The triumph of the quiet bureaucrat
Any of these initiatives could be applied practically anywhere and, although people already talk about ‘digital-era governance’, the technology involved is far from complex. So why have these tech successes come from, of all places in the world, Punjab and not Silicon Valley or other wealthy tech enclaves nearer to Pakistan?
The answer, Saif argues, lies in the fact that success is much more unglamorous perspiration than well-capitalised inspiration. ‘At times you really have to shove this down the throats of a lot of people. And you have to figure out all the dynamics. When we started, they said, We barely get time to vaccinate children, now you want us to report using smartphones. Once we had rolled out a small pilot, we could go back to them and say, That doesn’t seem like a lot of work. And then the next thing was, We don’t have enough petrol for our motorbikes to go from place to place to place. So we got them the petrol allowance and then started monitoring them.’
In the case of Punjab, the dengue pandemic provided the political will to come up with something new, and quickly. Moreover, Chief Minister Sharif, reputedly a tech enthusiast, has given the programmes the clout to, say, arrange petrol allowances for another agency, although Dr Saif stresses that he still has to pick his battles. He also has been given the resources to create software in-house, allowing rapid adjustment and fine-tuning as a particular situation becomes better understood.
The technology itself is so simple that Saif, with help from DFID, has built a free online platform called Dataplug where other governments or organisations, instead of writing their own code, can drag and drop components to create an application in a matter of minutes.
Against widespread excitement about the potential of data and new technologies, these astonishing successes in Pakistan are a triumph, as much as anything, of administration. As the modest Bhatti puts it, ‘I’m not an ICT person. I am a public administration person, so I am just looking at problems and seeing how you could solve them. Or address them; solving is a tall order.’
(Picture credit: Flickr/Muhammad Imran Saeed)