1. Dr Talib Lashari National Conference MDGs: Improving Maternal Health in Pakistan Margalla Hotel, Islamabad November 25-26, 2013 3 Years Since Devolution Stock Taking: Implications for MNCH

2. Overview Introduction Devolution: Cabinet Div, CCI, Federal Legislative List Implementing Devolution Reforms Vertical Programs – status MDGs targets MNCH: Inequities Challenges Conclusion Recommendations 2

3. Introduction Constitution (Eighteenth Amendment) Act 2010: paradigm shift Momentous change: health services placed closer to communities. Implementation has been challenging - preparedness at relevant levels Clarity regarding the roles and responsibilities :federal and provincial tier. 3

4. Introduction Cabinet Division notification of June 29, 2011: eight different Divisions assigned residual functions Planning Commission/P&D assigned the prime role of “national planning & coordination in the field of health” Recently, Ministry of National Health Services, Regulation and Coordination (NHSRC) established 4

5. Cabinet Division Notifications DateNotification December 2, 2010; April 5, 2011; and June 29, 2011: Devolution of 17 federal ministries to provinces. Devolved ministries also include Ministry of Population Welfare; and Ministry of Health. December 15, 2010Adjustment of employees of the devolved ministries/divisions to other ministries March 31, 2011Establishment of CADD July 29, 2011New ministries/divisions i.e. National Harmony; Human Resource Development; Professional and Technical Training October 26, 2011Four new Ministries along with Divisions i.e. National Heritage and Integration; Disaster Management; National Regulation and Services; Food Security and Research 5

6. Decisions of Council of Common Interest Council of Common Interest (CCI) held April 28, 2011 considered a summary submitted by the Finance Division. The CCI decided that the Federal Government shall provide funding for the vertical programs in Health The vertical programs in Health will receive funding at the level of 2010-11 budgeted level CCI also decided: The financing for development program of Population Welfare beyond June 2011 would depend upon the approval of ECNEC for this program. Later on the PC 1 of the Population program was approved. 6

7. Federal Legislative List Part IPart II Fourth Schedule, Article 70 (4). Legislative Lists Federal Legislative List Entry 3. International affairs; the implementing of treaties and agreements, including educational and cultural pacts and agreements with other countries Entry 11. Legal, medical and other professions. Part I: Entry 19. Port quarantine, seamen’s and marine hospitals and hospitals connected with port quarantine. Entry 32. International treaties, conventions and agreements and international arbitration Entry 17. Inquiries and statistics for the purpose of any of the matters in this Part. Part I: Entry 57. Inquiries and statistics for the purposes of any of the matters in this Part. Entry 7: National Planning & national economic coordination including planning and coordination of scientific and technological research. Entry 13. Inter-provincial matters and coordination 7

8. Implementing Devolution Reforms Tactical vs. Strategic Issues Planning Commission: Resolution of outstanding tactical issues being faced by provinces July 2011-June 2012: resolving tactical issues Devolution issues were also being discussed at i.e. IPC; High Powered Committee of the Cabinet; Devolution Cell at the Cabinet Division etc Concerns of Donor Pre devolution mechanisms need to be translated at provincial level Equality in donor support Concerns of Provinces releases of funds Level of funding Future of vertical programs donor grants Lack of flexibility in utilization Resource gap drug regulation Procurement 8

9. Devolution Reforms Inter Provincial Meetings Inter-provincial meeting January, 2012: – Current status and financing modalities for vertical health programs. – Provincial PC 1s at the fixed ceiling for PSDP FY 2010-11 as per decision of CCI – March, April, 2012 the matters related to Project Management Units (PMUs) with regard to Global Fund and GAVI discussed. – Mechanism of CCM – 3 PMUs shall function with a revised structure till currency of available GF grant February 24, 2012 on PC1s; sustainability of programs; liabilities; release of funds and PMUs: – pending releases – DFID component for MNCH – level of funding same with >salaries of LHWs Tactical issues resolved/Strategic Policy coordination Implementation of above mentioned decisions require a coordination mechanism at federal and provincial level 9

10. Status of Vertical Programs Program Post Devolution Status Status of Donor GrantRemarks Maternal, Neonatal Child Health Devolved to provinces DFID Grant streamlined, disbursed, MoU extended till March 2014 on no cost basis No PMU existing at federal level National Program of FP & PHC (LHW) Devolved to provinces No Donor GrantNo PMU exists at federal level Expanded Program on Immunization (EPI) Devolved to provinces (Polio Cell, EPI cell?) GAVI support for vaccine procurement and Health Systems Strengthening (HSS) available GAVI agreed to have a PC 1 for HSS to coordinate for systems strengthening to enhance immunization coverage No PMU at federal level. Provinces implementing EPI programs 10

11. MGDs 4&5 Economic Survey s; PHDS 1990;2007; 2012-13;MDGs Report 2010; PSLM 2004-05 Indicators19902000CurrentMDGs Human Development Index --146 (Low H D) Infant Mortality Rate 1027774 (NN 55; <5:89) 40 Maternal Mortality Ratio 533350276140 Contraceptive Prevalence Rate (%) 11.82835.455 Skilled Birth Attendants Coverage (%) 18.81952>90 Immunization (%) 517753 (measles 61.4) >90 11

12. MNCH: Inequities PDHS 2012-13 12 Fertility Rate

13. MNCH: Inequities PDHS 2012-13 13

14. MNCH: Inequities PDHS 2012-13 14

15. MNCH: Inequities PDHS 2012-13 15

16. Challenges Policy, Planning; Governance – Post devolution strategic issues – Coordinated policy framework based on provincial policies – Oversight, stewardship, evaluation – Donor coordination – Flow of information and surveillance – International commitments Programmatic – Resource gap: federal, provincial, donor funding – Need assessment by donor/NGOs based on PC 1 – MNCH program: weak public private partnership; linkages with PWD, LHWs; communication strategy – Releases, coordination 16

17. Conclusion Devolution has positive implications for MNCH; strategic & governance issues need to be addressed: which may affect gains Federal roles to be streamlined: Ministry of National Health Services, Regulation & Coordination (NHSRC) Federal, provincial, donor, INGOs/NGOs coordination for financing, procurement is weak Inequities hampering the achievement of MDGs 17

18. Recommendations Policy, Planning & Governance – NHSRC may focus on broader policy coordination, TA, facilitation, stewardship, inter provincial & donor coordination, international commitments (should not engage itself in project approach) – Coordinated Health Policy Framework Health Systems Strengthening Unit – Donor Coordination Strategy – Flow of information, IHR, vaccine procurement Programmatic – Federal, provincial & donor/INGOs, NGOs funding – gaps to fill in – Integration of programs – Targeted voucher schemes, alternative financing & poverty reduction initiatives (BISP) to address inequities in short to medium term 18

19. Thank you 19