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

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
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
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 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

10. 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.

11. 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 

12. 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.

13. 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

14. 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.

15. 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

16. 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.

17. 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

18. 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.

19. 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

20. 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.

21. 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.

22. 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.

23. 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.

24. 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

25. 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.

26. Thank You