Devolution in Health Sector Challenges and Opportunities for Evidence based Policies Dr. Babar Tasneem Shaikh

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 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 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 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

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.

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 

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.

Challenges and Constraints Health 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

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.

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

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.

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

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.

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 drugs stock outs Availability of essential health care products is the main challenge  

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 All provinces (including AJK and GB) working on them KPK had the first approved strategy Sindh and Punjab followed 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.

Health Systems & Policy Implementation Post-Devolution The Optimistic View Provinces now free to strategize, plan and act without federal dictation. Comes along the responsibility and accountability too! 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 Post-Devolution: The Down Side 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 Govt 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 preferring one-window dealing they might prefer to work with only some provinces based on their convenience.

Key Strategies for Health Systems Strengthening Building capacity for health system to deliver Improving health governance Balancing cost and sustainability 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 Making decisions on evidence base

Opportunities and the Way Forward Let’s educate ourselves, the partners, the communities and all other stakeholders. Interact closely with the provinces. Action oriented advocacy for plugging the gaps. Lobbying for appropriate checks and balances, and transparency to curb corruption. Contribute towards institutional strengthening and capacity building at the provincial level Let’s work together for a responsive service delivery system with elements of consistency, equity and quality.

Thank You