Devolution, Governance
& Health
Mohsin Saeed Khan
Ph.D, MPH, MBBS
Health Outcomes
Numbers/annum
Newborn births
4,773,000
Newborn deaths
272,330
Infant deaths
377,440
Under-five deaths (includes newborn and infant
deaths)
473,000
Number of Infants Born Low-Birth-Weight
906,870
Number of Maternal deaths
23,865
Source PDHS 2006-2007
Total Public Sector Expenditure
in Billions (Rupees)
90
80
70
60
50
40
30
20
10
0
Per Capita expenditure on
Health in Pak Rupees
500.0
450.0
400.0
350.0
300.0
250.0
200.0
150.0
100.0
50.0
0.0
Health Expenditure as % of
GDP
0.8
0.72
0.7
0.6
0.5
0.59
0.58
0.57
0.57
0.57
0.51
0.57
0.56
0.54
0.4
0.3
0.2
0.1
0
0.23
0.27
Health system assessment Approach, USAID
Devolution Road Map
 Ministry of Health since 1970
 2001 under the Local Government Ordinance;
Province to Districts
 July 1, 2011, 18th Constitutional Amendment
abolished seven federal ministries including
Ministry of Health and transferred their roles to
other federal ministries, divisions, and the
provinces.
Devolution Road Map
 vacuum
 as the devolved functions were not detailed
out in any plan of action.
 The functions that have been retained at the
federal level were distributed to different
ministries without setting up a coordination
mechanism.
The Federal Ministry of Health
 Till June 30, 2011, MoH responsible for
 (i) stewardship functions, including national policy
and planning;
 (ii) regulation and standardization including
pharmaceutical;
 (iii) medical Education;
 (iv) research and information;
 (v) central health establishment and hospitals; and
 (vi) health care provision by managing preventive and
infectious disease control (eleven vertical programs),
curative health care through tertiary care.
Fragmentation
1. Planning and Development Division,
2. Economic Affairs Division,
3. Capital Authority Development Department,
4. Ministry of Inter Provincial Coordination,
5. Ministry of National Regulations and Services,
6. Cabinet Division,
7. Federal Bureau of Statistics, and
8. Provinces.
Provinces
 Health Strategies in Khyber Pakhtunkhwa, Sindh and
Punjab
 Vertical Program Management without ownership
Programmatic Challenges
 Issues of coverage (scope & scale)
 Poor access to health services
 Non-availability of adequate human resource
 Population growth
 Low allocations for health
 Weak inter-sectoral interventions
 Duplication of efforts
Service & Performance Challenges
 Financial instability
 No accountability for poor performance
 Political interference
 Issues of equity
 Skilled HR
Confusion, Chaos & Collapse
 coordination,
 international relationships,
 national and cross border surveillance,
 national information on health,
 international reporting coordination with and among
provinces,
 donor coordination,
 financial forecasting and resource mobilization, and
 quality assurance
Actors
 Politicians – Out Focused
 Beurocrats – Input Focused
 Technocrat – Process oriented
 Research & Development Specialists /
Institutions – Driven by TORs
 Donors – Guided by their own sets of
priorities
So where do we want to go
 Vision !!!!!!!!!
 Not on priority list
 Burden of Disease (outcome)
 Not in the planning process
 Fiscal Space
 Management systems and organizational structures
 What is beyond MDGs
IK IK Syndrome
On “bottlenecks”
Remember that in bottles, the neck is always on the top!
Insight from a blind woman
“There is nothing more pathetic
than a man with eyesight but has
no vision.”
Our best thinking got us here.
The problems that we face cannot be
solved by the same level of thinking that
created them.
Albert Einstein
Way Forward
 Embrace Error
 Redefine Roles
 Deliver Services
 Mobilize Resources
 Unpack Research
THE WISDOM OF TAO
XVII RULERS
Of the best rulers
The people only know that they exist,
The next best they love and praise,
The next they fear;
And the next they revile.
When they do not command the people's faith,
Some will lose faith in them,
And then they resort to oaths!
But of the best when their task is accomplished, their work done,
The people all remark, "We have done it ourselves."
Source: The Wisdom of China and India by Lin Yuntang