1. DEVOLUTION PLAN AND HEALTH CARE IN PAKISTAN CHALLENGES AND CONSTRAINTS Dr. Babar T. Shaikh The Aga Khan University, Karachi, Pakistan.

2. VISION Health is a basic human right and must be available and accessible in an affordable framework to all. To this end, an integrated approach to public health in the district will combine preventive, promotive and curative health at all levels. Reductions in demand of curative care, would be translated into improvements in its quality.Health is a basic human right and must be available and accessible in an affordable framework to all. To this end, an integrated approach to public health in the district will combine preventive, promotive and curative health at all levels. Reductions in demand of curative care, would be translated into improvements in its quality. Promoting good governance in health sector, by meaningful and consistent emphasis on prompt, equitable and professional services delivery, must become a cardinal principle of the department.Promoting good governance in health sector, by meaningful and consistent emphasis on prompt, equitable and professional services delivery, must become a cardinal principle of the department.

3. Devolution, Decentralization, Debundling It is the transfer of authority, or disposal of power in public planning, management and decision making from the national level to sub- national levels or from a higher to lower levels of government.

4. Main Objective: philosophical & ideological Providing the means for community participation and local self-reliance and ensuring the accountability of government officials to the population.

5. DEVOLUTION OF POWERS IN HEALTH DEPARTMENT OBJECTIVES Empowerment of the people at the grass root level.Empowerment of the people at the grass root level. To make the District the dominant level of decision making in health department.To make the District the dominant level of decision making in health department. Improve the quantity and quality of health care delivery to the people close to their door steps.Improve the quantity and quality of health care delivery to the people close to their door steps. Integrated approach to public health, combining, preventive, promotive and curative health at all levels.Integrated approach to public health, combining, preventive, promotive and curative health at all levels.

6. RESPONSIBILITIES/ FUNCTIONS AT THE DISTRICT LEVEL Prevent and Control Communicable Diseases and Non Communicable Diseases. Prevent and Control Communicable Diseases and Non Communicable Diseases. Food Sanitation. Food Sanitation. Maintain medical and health statistics under HMIS. Maintain medical and health statistics under HMIS. Reproductive Health. Reproductive Health. Health and Nutrition Education. Health and Nutrition Education. Environmental and Occupational Health. Environmental and Occupational Health.

7. RESPONSIBILITIES/ FUNCTIONS AT THE PROVINCIAL LEVEL Make Health Policy for the Province. Make Health Policy for the Province. Legislate on Provincial health Issues. Legislate on Provincial health Issues. Drugs control under the Drugs Control Act. Drugs control under the Drugs Control Act. Monitoring and Regulatory functions of Medical and Para Medical institutions. Monitoring and Regulatory functions of Medical and Para Medical institutions. Health Research and related Health information gathering. Health Research and related Health information gathering.

8. RESOURCE/ASSETS DISTRIBUTION FOR THE DISTRICT Type-A or B [DHQ Hospital] hospitals. Type-A or B [DHQ Hospital] hospitals. Type-C [Tehsil HQ] hospitals. Type-C [Tehsil HQ] hospitals. Type-D [Civil] Hospitals Type-D [Civil] Hospitals RHCs. RHCs. BHUs. BHUs. Sub Health Centres. Sub Health Centres. MCH centres. MCH centres. Dispensaries. Dispensaries. Districts will be encouraged to establish their own Nursing, Districts will be encouraged to establish their own Nursing, LHV and Paramedical Training Institutes in due course. LHV and Paramedical Training Institutes in due course.

9. PROGRESS SO FAR Posts in Directorate General of Health Services have been re-designatedPosts in Directorate General of Health Services have been re-designated Budgets according to the new requirements.Budgets according to the new requirements. All DHOs and ADHOs have been briefed by the department twice on its approved Devolution plan.All DHOs and ADHOs have been briefed by the department twice on its approved Devolution plan. Briefing was held for both DHOs and DCs of all districts by Health DepartmentBriefing was held for both DHOs and DCs of all districts by Health Department All DHOs have been instructed to work as a team with the DCs at the district levelAll DHOs have been instructed to work as a team with the DCs at the district level All DHOs have been asked to develop lists of their assets for distributionAll DHOs have been asked to develop lists of their assets for distribution

10. Public Health District Headquarters Hospitals Basic Rural Health Centre Mother & Child Health Population Welfare EDO: Finance and Planning Health District Coordination Officer DISTRICT ADMINISTRATIVE STRUCTURE:

11. FUNCTIONS OF EXECUTIVE DISTRICT OFFICER Ensure that the business of the department and offices placed under his administrative control is carried out in accordance with the relevant laws and rules. Ensure that the business of the department and offices placed under his administrative control is carried out in accordance with the relevant laws and rules. Co-ordinate and supervise the activities of the relevant offices. Co-ordinate and supervise the activities of the relevant offices. Ensure efficient services delivery by functionaries under his control. Ensure efficient services delivery by functionaries under his control.

12. DISTRICT HEALTH MANAGEMENT TEAM What is the purpose of a DHMT ?  Develop a Team approach  Share and Exchange Views  Reduce the workload of the DHO  Optimize Utilization of the Human Resources  Improve Cooperation and Collaboration among stakeholders

13. How is a DHMT Constituted ?  DHO  Other District Managers  Public Sector Health Care Providers  Private Sector Health Care Providers  Community or its elected leaders

14. Role of DHMT  Sharing of experiences and exchanging of views & ideas.  Taking responsibilities and improving technical efficiency by supporting, assisting.  Improve cooperation and collaboration with the Government and private health related sectors.

15. OUTCOMES Well-defined structures have been developed and resources allocated. Well-defined structures have been developed and resources allocated. Meaningful partnerships at provincial, district, tehsil and community level, through the establishment of DHMT,THMT and citizen boards. Meaningful partnerships at provincial, district, tehsil and community level, through the establishment of DHMT,THMT and citizen boards. Detailed mapping of resources and services need to be developed. Detailed mapping of resources and services need to be developed. In planning and implementation of program a right based and integrated approach needs to be developed. In planning and implementation of program a right based and integrated approach needs to be developed. Meaningful action and capacity building would be required at all levels. Meaningful action and capacity building would be required at all levels.

16. HEALTH EXPENDITURE SITUATION AT PRESENT Almost 100% is out-of pocket Almost 100% is out-of pocket Includes formal and informal private sector Includes formal and informal private sector Questionable quality of care Questionable quality of care Considerable expenditures on unnecessary and inappropriate (sometimes unsafe) care Considerable expenditures on unnecessary and inappropriate (sometimes unsafe) care Inequity in financing of care Inequity in financing of care No regulation or standards on fee charged No regulation or standards on fee charged Reliable information not available Reliable information not available

17. ADVANTAGES OF DEVOLVED SYSTEM IN HEALTH CARE Administrative and financial powers to district authorities / local bodies representative.Administrative and financial powers to district authorities / local bodies representative. Involvement in devising the programs relevant to the local needs and priorities.Involvement in devising the programs relevant to the local needs and priorities. Strategies and plans acceptable for the community and matching to their socio cultural and socio economic background.Strategies and plans acceptable for the community and matching to their socio cultural and socio economic background.

18. User willingness to pay for PHC in the public sector services, if they receive improved care.User willingness to pay for PHC in the public sector services, if they receive improved care. The districts can recover substantial costs and can retain the incomes.The districts can recover substantial costs and can retain the incomes. Creating sense of ownership.Creating sense of ownership. Strengthening of FLCF, answering many primary health problems like high IMR, high MMR and morbidity and male involvement.Strengthening of FLCF, answering many primary health problems like high IMR, high MMR and morbidity and male involvement.

19. CRITERIA FOR ALLOCATING DISTRICT BUDGETS Population Size Population Size Socio-economic Development Socio-economic Development Health Infrastructure Health Infrastructure Health Needs / Problems (BOD Estimation) Health Needs / Problems (BOD Estimation) Performance Evaluation based on Performance Evaluation based on predetermined indicators predetermined indicators Combination of Above Combination of Above

20. CHALLENGES AND CONSTRAINTS Political willingness of provincial and district governments to work in the new system.Political willingness of provincial and district governments to work in the new system. Defining their administrative roles with limits and jurisdiction.Defining their administrative roles with limits and jurisdiction. Distribution of financial powers between Provincial and District representatives. (dependency of districts on provinces for how long?)Distribution of financial powers between Provincial and District representatives. (dependency of districts on provinces for how long?)

21. Financial and administrative capacity of the district government.Financial and administrative capacity of the district government. Resentment against the status quo at the provincial level and fear of loosing authority.Resentment against the status quo at the provincial level and fear of loosing authority. Lack of trust and losing the profit.Lack of trust and losing the profit. Status of Public Service Commission, Medical colleges and Tertiary hospitals.Status of Public Service Commission, Medical colleges and Tertiary hospitals.

22. THE INTERNATIONAL DEVELOPMENT TARGETS 1. A reduction by one half in the proportion of people living in extreme poverty by 2015 2. Demonstrated progress towards gender equality and the empowerment of women by elimination gender disparity in primary and secondary education by 2005 3. A reduction by two-thirds in the mortality rates for infants and children under age 5 and reduction by three-fourths in maternal mortality - all by 2015