Devolution in Pakistan: the 18 th Amendment

1. Devolution in Health SectorChallenges and Opportunities for Evidence based Policiesby Dr. Babar Tasneem ShaikhDecember 14, 2012

2. 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

3. 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

4. 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

5. Post 18th Amendment Scenario • 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

6. Post-18th Amendment Scenario • 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

7. 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

8. Challenges and Constraints • WHO framework on building blocks of health system • Governance • Service Delivery • Health information • Financing • Human Resources • Medical Products/Technologies

9. Challenges and ConstraintsGovernance • 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

10. 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 

11. Challenges and ConstraintsHealth Information • 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

12. Challenges and ConstraintsHuman 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

13. Challenges and ConstraintsHealth 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

14. Challenges and ConstraintsMedical 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

15. Provincial Health Sector Strategies • 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

16. 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 under-developed 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.

17. 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.

18. Provincial Health Sector StrategiesHuman 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.

19. Provincial Health Sector StrategiesDrugs, 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.

20. 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.

21. 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.

22. Health Systems & Policy Implementation Post-Devolution 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.

23. Health Systems & Policy Implementation Post-Devolution: 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

24. Key Strategies for Health Systems Strengthening • 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

25. 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.

26. Thank You