Devolution in Health
Sector
Challenges and Opportunities
for
Evidence based Policies
by
Dr. Babar Tasneem Shaikh
December 14, 2012
Devolution in Pakistan: the 18th Amendment
• Before the present devolution
– Devolution in 2001 (LGO 2001)
– District Health System
• Under 18th amendment
– Abolition of the concurrent list
– 18 ministries including health and population
welfare totally devolved
Devolution in Pakistan: the 18th Amendment
• Concurrently:
– NFC Award of 2010-11
– Unprecedented share of finances and other resources
transferred to provinces
• However:
– Unlike education, health care not a fundamental right
– Progress in health indicators (MDGs 4, 5 & 6) very slow
• Associated health system constraints
Pre-18th Amendment Scenario
• Federal Ministry of Health in the driving seat
• Operating through the concurrent legislative list
• Managing:
– Provincial health departments
– Eleven vertical programs
– Seven tertiary care centers
– National Health MIS and other Info Systems
Post 18th Amendment Scenario
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Provinces more empowered to operate their health systems
Ministry of Health abolished
CCI - the link between Federal & Provincial Governments
Federal Gov can only legislate on subjects in second part of
Federal Legislative Lists
• Some functions of MoH delegated to eight institutional
settings, which are:
– Ministry of Inter Provincial Coordination (IPC)
– Ministry of National Regulation & Services
– EAD, Cabinet Div, P&D, FBS, Capital Admin & Dev
Post-18th Amendment Scenario
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Policy formulation and health planning devolved
Service delivery now entirely with the provinces
National HMIS replaced with District Health IS
Some programs – TB, Malaria and AIDS etc. – retained:
– Under contractual agreement
– With the Ministry of IPC
• Drug Regulatory Authority also retained
Challenges and Constraints
• Achievement of health related MDGs
– MoH abolished
– Leaving many areas unattended
• Issues of capacity in the provinces – at least initially - in:
– Health planning and regulation of policies
– Strategic directions and leadership
– Health information generation
– Human resource development
– International agreements
Challenges and Constraints
• WHO framework on building blocks of health system
– Governance
– Service Delivery
– Health information
– Financing
– Human Resources
– Medical Products/Technologies
Challenges and Constraints
Governance
• Absence of adequate policy framework
• Absence of inter provincial harmonization on health policy
development
• Absence of federal regulatory authority for coordination
– International relationships
– National health info and reporting mechanisms
– Financial forecasting
– Donor coordination
• Fragmented functions and distributed coordination activities
• Creation of good administration and fair governance
• Lessons from LGO 2001 implementation
Challenges and Constraints
Service Delivery
• Financial transfer sudden and without optimal technical
guidance
• Vertical programs facing issues of fiscal support
• Challenges of national service delivery programs
– Inter-provincial harmonization
– Contractual agreements
– Resource mobilization
– Donor preferences for one window operations
Challenges and Constraints
Health Information
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Lack of integrated disease surveillance system
Lack of inter-provincial info sharing mechanisms
Absence of collated info and irregular reporting
So there is limited utilization of info and evidence for
– Planning in national programs
– Assessment of health services
– Surveillance in case of disease security
• Results in constrained decision making
Challenges and Constraints
Human Resource
• Lack of trained staff resulting in
– Underutilization of primary health care services
• Uneven deployment in urban and rural areas
• Absorption of federal staff – additional financial burden
• Concerns about service structures – strikes by
– Young doctors
– Nurses
– Paramedical staff
Challenges and Constraints
Health Financing
• Provinces have up to 40% more funds, but
– Weakly planned process of reforms
– Slow transfer of funds, and so
– Vertical health programs facing problems
• No performance parameters due to lack of collated info
• Poor resource tracking
• Compilation of provincial health accounts is a key challenge
• With only 0.25% GDP spent on health, increase in financial
outlay is an imperative
Challenges and Constraints
Medical Products/Technologies
• Centralized authority is required, hence retained at the
federal level for
– Standardization and manufacture
– Regulation of drugs, and
– Administrative control of institutes
• Lack of drugs leading to underutilization of public healthcare
• Lack of Logistic Management Info System (LMIS) leading to
lack of drugs
• Availability of essential health care products is the main
challenge
Provincial Health Sector Strategies
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All provinces (including AJK and GB) working on them
KPK has now an approved strategy
Sindh and Punjab to follow suite
Similarly for AJK and GB
Baluchistan, with its peculiar problems, somewhat lagging
behind but working on it
• Salient features of these provincial strategies given in the
paper
• Key common features discussed in the following slides
Provincial Health Sector Strategies
Governance
• Review of stewardship function of DoH by re-aligning its
functions of policy development, planning, reforms,
monitoring and evaluation etc.
• Establish a Policy Planning Unit at provincial level and staff it
with competent professionals after competitive selection.
• Strengthen district health systems starting with most underdeveloped districts.
• Regulate the health sector, in particular the extensive private
sector towards licensed practice, standardization of care,
minimal reporting requirements and address of medical
negligence.
Provincial Health Sector Strategies
Information System
• Integrate all national programmes’ information systems into
the DHIS and establish functional linkages between all levels
of operation (facilities, district, provincial or federal
management).
• Revisit the scope and content of the DHIS so as to integrate
data from LHW, MNCH and DEWS etc.
• Link tertiary care and the private sector health facilities with
district and provincial level information systems.
Provincial Health Sector Strategies
Human Resources
• Streamline human resource production, retention and
capacity to support priority heath needs.
• Strengthen the personnel section at DoH to perform all
human resource management functions.
• Develop a continuing medical education program for all
medical, nursing and paramedical staff linked to career
development.
Provincial Health Sector Strategies
Drugs, Supplies & Technologies
• Improve availability of quality essential medicines in health
facilities based on standardized services at each level.
• Improve logistic and supply chain management system for
regular, uninterrupted and adequate availability of essential
drugs at all levels of health care.
• Establish a procurement and logistic cell at the provincial level
and to implement PPRA rules and regulation for public sector
drugs procurement.
• Implement and revisit EDL for all levels of health care
according to the burden of diseases of the population served.
Provincial Health Sector Strategies
Financing
• Allocate resources according to incidence and prevalence of diseases, cost
effectiveness of a programme/ policy, and poverty levels.
• Introduce safety nets to protect poor from catastrophic expenditures e.g.
social health insurance, community based health insurance, vouchers.
• Implement an integrated budgetary planning process whereby DoH has
the mainstay in consultation with Finance and Planning Departments.
• Align the donor funding with DoH strategy and priority areas for
investment.
• Introduce social health insurance and other safety nets protecting the
disadvantaged and vulnerable from catastrophic health expenditures.
Provincial Health Sector Strategies
Service delivery
• Develop, cost and implement an Essential Health Service
Package at Primary & Secondary levels.
• Revitalize the delivery of family planning services in the public
sector health facilities.
• Institutionalize an operational referral system from primary to
secondary and from secondary to tertiary healthcare level.
• Re-align the MNCH strategies and activities in the light of
findings of DHS.
• Increase coverage and utilization of quality services at
primary & secondary health care levels by implementing
EHSP.
Health Systems & Policy Implementation PostDevolution
The Optimistic View
• Provinces now free to strategize, plan and act without federal
dictation.
• Able to provide vision, roadmap and framework for steering health
affairs.
• Strategies being developed are more relevant and context based on
fresh, sound and situation analyses.
• More intense and deeper consultation would result in greater
ownership by provincial stakeholders.
• All strategies following WHO standards and building blocks with
uniform framework for benchmarking.
• Participated, approved and owned strategies have the potential to
transform the system.
Health Systems & Policy Implementation PostDevolution: The Down Side
• The whole process suffered from a knee jerk reaction from the provincial
govts – complaints of being unprepared, incapacitated and perhaps
unaware of the implications
• An integrated and unified vision of health for all –
– Who would ensure a common national vision and cohesive mission?
– Would every province have a different vision, strategy and goals?
– Would there still be a role of the Federal Gov in this regard?
• Regulation and standardization now also ideally lie with the provinces.
How would this responsibility carried out in the future?
• What about the much needed inter-provincial harmony? Who will be the
moderator between the provinces?
• Donors and development partners are still in a state of ambiguity.
Wanting one-window dealing they might prefer to work with only some
provinces based on their convenience
Key Strategies for Health Systems Strengthening
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Building capacity for health system to deliver
Balancing cost and sustainability
Improving health governance
Protecting people from financial risks
Measuring and monitoring health system’s performance
Paying for results to improve health system’s performance
Tracking expenditures through health systems
Allocating human resources to health systems
Opportunities and the Way Forward
• First and foremost: educate ourselves, the partners, the communities and
all other stakeholders.
• It is imperative to interact closely with the provinces, and barring few
areas, less with the federal tier.
• Pragmatic approach to embark upon an action oriented advocacy for
plugging the gaps.
• Lobbying for appropriate checks and balances and transparency to curb
corruption.
• Need for institutional strengthening and capacity building at the provincial
level to
– Ensure responsive service delivery with consistency and quality
• All criticism apart, this is a unique window of opportunity to re-orient and
overhaul the public health system.
Thank You