devolution in health sector - lead.org.pk in health challenges and...table of contents foreword 01...

Devolution in Health SectorChallenges & Opportunities for Evidence Based Policies

Dr. Babar Tasneem Shaikh

Authorship & CopyrightsDr. Babar Tasneem Shaikh is one of the leading public health experts in the country with areas of interest in Health Systems, Health Policy and Health Systems Reforms. He has worked on themes such as quality of care, access to health care especially for women and children, health systems strengthening through decentralization, and public private partnership in primary health care revitalization in the country. His flagship work on health seeking behaviours and health services utilization has become a cutting edge in the field. His research work is extensively disseminated through more than 70 peer reviewed publications in both national and international indexed journals. Besides his articles, he has published training manuals, research reports, position papers and a chapter in the book titled Health System of Pakistan.

The work is commissioned by Lead Pakistan, a non-governmental organization which has a mission to create and nurture networks of people and institutions promoting change towards the sustainable development – the development that is economically sound, environmentally responsible and socially equitable.

AIDS Acquired Immuno-Deficiency Syndrome

AJK Azad Jammu & Kashmir

BHU Basic Health Unit

BISP Benazir Income Support Program

CCI Council of Common Interests

CMW Community Midwife

DEWS Disease Early Warning System

DGHS Director General Health Services

DHIS District Health Information System

DoH Department of Health (Provincial)

DTL Drug Testing Laboratory

EDL Essential Drug List

EHSP Essential Health Service Package

EPI Expanded Program of Immunization

FLL Federal Legislative List

GB Gilgit-Baltistan

GDP Gross Domestic Product

GFATM Global Fund for AIDS, TB & Malaria

HR Human Resources

HRIS Human Resource Information System

IMNCI Integrated Management of Neonatal & Child Illnesses

IPAP Information, Planning and Policy

LHW Lady Health Worker

LMIS Logistics Management Information System

MHSP Minimum Health Services Package

MNCH Maternal, Neonatal & Child Health

MoH Ministry of Health (Federal)

MSDP Minimum Service Delivery Package

MSDS Minimum Service Delivery Standards

NCD Non-Communicable Diseases

NFC National Finance Commission

NGO Non-Governmental Organization

NNS National Nutrition Survey

OOP Out of Pocket (expense)

PDHS Pakistan Demographic & Health Survey

PHC Primary Health Care

PHSA Provincial Health Services Academy

PPRA Pakistan Procurement Regulatory Authority

PSLSM Pakistan Survey of Living Standards Measurement

PWD Population Welfare Department (Provincial)

RHC Rural Health Center

TB Tuberculosis

UN United Nations

WHO World Health Organization

Abbreviations and Acronyms

Table of ContentsForeword 01Executive Summary 02Introduction 03

Objectives of Devolution in Health Sector 03Guiding principles and pre-requisites 03

Devolution in Pakistan: the 18th amendment 04Pre-18th amendment scenario 04Post-18th amendment scenario 05

Challenges 06a)Governance 06b)Service Delivery 06c)Health Information 07d)Human Resource 07e)Health Financing 07f)Medical Products/Technologies 08

Salient features of provincial health sector strategies 081.Punjab 082.Khyber Pakhtunkhwa 093.Sindh 104.Balochistan 105.Azad Jammu & Kashmir 116.Gilgit-Baltistan 12

Health Systems & Policy Implications after Devolution 13The optimistic view 13The down side 13

Key strategies for health systems strengthening 14a)Building capacity of health system to deliver 14b)Balancing cost and sustainability 15c)Improving health governance 15d)Protecting people from financial risks 15e)Measuring and monitoring health system’s performance 16f)Paying for results to improve health system’s performance 16g)Tracking expenditures through health systems 16h)Allocating human resources to health system 17

Opportunities & Way forward 18Acknowledgements 18References 19

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Foreword

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LEAD PakistanOccasional Paper Series

LEAD Pakistan in partnership with David & Lucile Packard Foundation has launched “Our World- Women Leadership in Reproductive Health & Development”, a project that aims to sensitize a cross-sectoral network of leaders and motivate them to raise the profile of reproductive health in the social development sector through public policy engagement and media. The goal of the project is to generate debate and dialogue with multi-sectoral experts, academics, intellectuals and policy makers on pertinent issues in the field of health, climate change and human develop to enable informed policy making.

With the deadline of Millennium Development Goals approaching near, Pakistan needs to assess its position on the health status of its nation. The health of its citizens is amongst the poorest in the world. The state's healthcare system has suffered a lot, owing to structural fragmentation, resource scarcity, inefficiency and lack of functional specificity, gender insensitivity and inaccessibility. Given the eighth highest newborn death rate in the world, between 2001 to 2007 one in every ten children born in Pakistan died before reaching the age of five. Similarly for women, there is a one in eighty chance of dying of maternal causes during reproductive life. Compared to other South Asian countries, Pakistan currently lags behind in immunization coverage, contraceptive usage and infant and child mortality rates.

This called for innovative and sweeping changes, the basis for which, it seems, has been laid by the 18th amendment, albeit without the intention of its authors. However, the 18th amendment has indeed ushered in new opportunities and challenges of governance, legislation, management, leadership, financing, resource allocation, human resource, monitoring, coordination, compliance and service delivery. It has brought a new shift of power and responsibilities between the federation and provinces. With decentralization, there are opportunities for streamlined processes, more accountability, increased autonomy for decision making, evidence based estimation and management of human and financial resources, increased capacity building of health workforce and an overall pragmatic, practical and realistic approach of health care management. This offers a chance to rebuild the ailing health system, but these opportunities come with innumerable challenges as well.

This paper explores pre- and post-devolution status of health related subjects following abolition of the Federal Ministry of Health. It highlights the implication of devolution on governance, service delivery, health information, medical and drug regulations, human resource and healthcare financing based on the six pillars of the WHO framework. It also presents outlines of proposed strategies that the provinces have developed in the wake of devolution. Listing and briefly discussing all key issues of the health sector before and after devolution, the goal of this comprehensive study is to encourage debate and discussion on policy implications, providing insight on future roadmap for the provinces. Through this paper, LEAD has attempted to demystify the devolution process and understand the impact of 18th amendment on health reforms. We hope it will adequately serve the purpose for which it was conceived and actualized.

Ali T. SheikhCEO, LEAD Pakistan

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Health system in Pakistan has been lagging behind in terms of key health indicators of maternal

and child health as well as of Tuberculosis, Malaria and HIV/AIDS. To accelerate the pace toward

achieving or at least nearing the Millennium Development Goals and targets concerned, it would

be imperative to take some radical and rational steps for improving the performance of our health

system. There is growing evidence that decentralized sharing of powers can bring decision-makers

and service providers closer, better informed and more accountable to populations they serve.

Pakistan has undergone organizational reforms through a constitutional amendment in June 2011

(famous as 18th amendment). Health as a result becomes solely a provincial subject. Since

provinces are autonomous and constitutionally more powerful to decide for their health systems

roadmaps, it is very opportune time for all of them to consider and employ best practices and opt

advocated strategies for health system strengthening worldwide. Issues of governance, financing,

human resource and service delivery ought to be taken on priority for the sake of serving the

poverty struck people of Pakistan. These are some of the imperatives for ensuring the equity,

efficiency, quality and financial soundness in the new devolved system. The commitment to

achieve the health related Millennium Development Goals becomes even more challenging.

This paper has endeavored to analyze the WHO framework on building blocks of health system to

catalogue challenges and constraints in wake of recent health reforms. These are, governance,

service delivery, health information, financing, human resource and medical

products/technologies. Salient features of all the provincial health sectors and their respective

strategies (Punjab, Khyber Pakhtunkhwa, Sindh, Balochistan, AJK, & Gilgit-Baltistan) are presented

so that readers can appraise whether these 5 years plans made by the provinces, will suffice to

meet the requirements, demands and challenges of provincial health systems.

Last part of the paper deliberates on the health systems and policy implications of the devolution,

presenting both positive and negative sides of the phenomenon. Key strategies for health system

strengthening are proposed with an aim to assist the provincial governments to benefit from these

guidelines. For non-government outfits, this paper will be an effective advocacy tool for lobbying

with the government entities and providing technical assistance wherever the need is felt.

Executive Summary

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Globally, 115 countries in the world health and social sectors in various countries

unambiguously recognize right to health, but across the continents. Absence of a national

not the constitution of Pakistan. With recent policy and stance, the inequities in the

promulgation of 18th amendment in Pakistan, distribution of finances, human resources and

education is included as fundamental human structures can even deteriorate. There is a

right, whereas right to health has yet not likelihood of an increased inefficiency due to

accorded any attention. Health for all is not gaps in the managerial capacity of sub-

treated as a legislative subject, though some national tiers of the government. Moreover,

of the subjects related to health are included the political pressures can escalate on local

in the legislative list of the Constitution of managers, and corruption may become more

Pakistan. rampant with the availability of increased

resources and weakened monitoring and

evaluation of health system performance. At Ratification of this famous amendment

times, the decentralization makes it more decentralized decision-making on health

difficult pursuing coherence of local plans with related subjects to the four provincial health

national goals and policies. This scenario is departments of Pakistan. Decentralization

even worse where the sub-national capacity mostly driven through political pressures as

and an overall environment are weak. The the case in Pakistan may have various forms

overarching objectives, however, behind any such as de-concentration, delegation,

devolution focus the empowerment of the devolution and privatization. The over overall

people at grass roots level and ensuring a purpose is to share powers and take decisions

bottom up decision making process. It is also at decentralized level (district or provincial) of

envisaged that quality health care will be health system. There is growing evidence that

provided with an integrated approach and decentralized sharing of powers can bring

resource pooling. Sub national units will be decision-makers and service providers closer,

able to develop their own human resource better informed and more accountable to

and therefore will address the issue of populations, they serve. Decentralization tends

programmatic sustainability. Lastly, devolution to simplify management and enhance the

is considered to bear fruits of governance in efficient use of resources, ensuring equity in

the shape of prompt, equitable & professional terms of improved access to and delivery of

services. health services for the under-served,

marginalized, vulnerable and remotely located

population groups. Decentralization as a

national agenda involves other sectors, thus Lately, WHO presented the guiding principles promoting an inter-sectoral collaboration, as pre-requisites for a successful which is a cornerstone for revitalization of decentralization of health services such as, Primary Health Care (PHC) services in political context, organizational change, developing countries like Pakistan. As a result, forecasting realistic goals, compliance with responsiveness of health system can be legal and regulatory framework, evidence improved as well as the quality of health based estimation and management of human services. and financial resources, capacity building of

health workforce and monitoring and

evaluation to practice equity, efficiency, quality

and financial soundness of the new system.Mixed results have been yielded as a result of

decentralization or devolution of power in

Guiding principles and pre-requisites

Objectives of Devolution in Health Sector

Introduction

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The health system of Pakistan has experienced slowly towards attainment of Millennium

chronological evolution of reforms since its Development Goals 4, 5 & 6. Maternal,

establishment. Decentralization in Pakistan neonatal, and child health indicators are below

predominantly resulted as a consequence of par, and are associated with health system

democratic political decisions; nevertheless, constraints. World Health Report prioritizes

there were economic, legal and organizational focus equities in health, access to care and

reasons behind these reforms. One of the quality of health care and it identifies primary

hallmarks was devolution of powers in 2001 health care as a key to strengthen health

which led to decentralization of health system. Recent reforms in Pakistan bring an

services and hence creation of district health opportunity to align by and large vision for

system. Yet again, two momentous reforms health and development as well as make a

related to constitution and fiscal relationship difference in rural population of four provinces

among provinces and federation have that is in dire need for essential health

undergone a drastic change. packages.

These organizational and fiscal reforms are This paper will present pre-and post-

18th Constitutional amendment (2010-2011) devolution status of health related subjects

and 7th National Finance Commission Award following abolition of federal Ministry of

(NFC) of 2010-11,. Under NFC Award, Health. The implications of devolution on

remarkable share of finances and other governance, service delivery, health

resourses have been transferred to provinces. information, medical and drug regulations,

The 18th amendment has shifted human resource and healthcare financing will

administrative and financial powers to also be discussed. Finally this paper will

provinces due to abolition of concurrent catalogue threats and opportunities for

legislative list. As a result, 18 ministries healthcare provision by provinces in post

including health, population welfare and other devolution scenario.

social sectors have been removed from the

federal list in the of the constitution of 1973.

New constitutional provisions pertaining to During pre-18th amendment scenario, two

health related subjects have been added to legislative lists (federal and concurrent), were

federal legislative list as a result of recent part of the constitution to set sharing of

overdue reform phase. Ironically, health is still legislative powers between federal and

not mentioned as a fundamental right in provincial assemblies on various portfolios.

constitution of Pakistan which may have The Ministry of Health (MoH) was operating

serious repercussions on policy and through concurrent legislative list and was

management of health sector in wake of managing provincial health departments,

recent reforms particularly when unplanned eleven vertical programs and seven tertiary

transfer of resources are taken into account. care centers.

The 18th amendment brings a major change

in structures, service delivery and resource

generation between federal and provincial With a few exceptions, the MoH performed governments. number of functions such as role of

stewardship including policy-making,

standardization of guidelines, formulation of Despite having significant health reforms with

academic policies for all cadres of health new administrative and financial control of

workforce, dealing with foreign governments provinces over health related subjects, the

and agencies, international commitments and country's health indicators have progressed

agreements. The standardization, registration

Pre-18th amendment scenario

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Devolution in Pakistan: the 18th amendment

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and pricing of medicines were a federal

responsibility, with the provinces involved only

in quality control issues. All the financing

mechanisms such as collecting, pooling and

purchasing for health were federal

prerogatives. Furthermore, Federal Ministry of The stewardship functions such as policy

Health was implementing eleven vertical formulation and use of evidence in health

priority preventive programs notably those for planning has been devolved to provinces. The

the lady health workers, maternal, neonatal provinces have now have control over to plan

and child health, tuberculosis control, malaria their own health needs and evidence based

control, national AIDS control program, EPI, policies. Service delivery programs which

control of hepatitis, and prevention of focus on vulnerable segments of the Pakistan

blindness program. While all these programs population can help provincial governments to

received funding from bilateral/multilateral meet health needs through decentralized

donors and/or UN agencies, they were also decision making. Yet under contractual

co-funded by the provincial exchequer, with arrangements, some programs such as TB,

some federal support both in financial and Malaria and AIDS have been retained with

technical terms. Although some of these Federal Ministry Of Inter-Provincial

vertical programs were financed exclusively by Coordination. Following organizational reforms,

the federal ministry, National Health provinces will get enhanced financial share

Management Information System and other under 7th NFC awards. However, service

parallel information systems of specific delivery programs are facing financial

programs on family planning and primary constraints from the federation and respective

health care, EPI, tuberculosis, AIDS, malaria etc provincial health departments during this

were being operated at the federal level. interim phase of organizational reforms.

Pakistan has history of allocating more of its

health budget on secondary and tertiary care

as compared to primary health care. At

present, provinces have leverage to spend

more in primary health care system to

improve efficiency and utilization of health

services. National Health Management

Information System has been replaced with

District Health Information System where

information flow mechanism is from first level

care facilities to provincial health departments.

Drug Regulatory Authority for standardization,

legislation and administration of drugs has

been retained with the federation in the post

18th amendment scenario.

Manifestly, recent wave of organizational

reforms has devolved other social sectors

including health to provinces. While

envisaging six building blocks of health

system, many functions and coordination

mechanisms of the abolished MoH are

fragmented and distributed to various

institutional settings in the central ministries.

Post-18th amendment scenario

Provincial Coordination, Ministry of National

Regulation and Services, Capital Administration

& Development and Federal Bureau of

Statistics.

By virtue of exclusion of concurrent list and

shifting of some health related subjects to

federal list, the provinces will be more

empowered to operate their respective health

systems, financially and administratively. The

second part of the Federal Legislative List (FLL)

is influenced by the Council of Common

Interests (CCI). The CCI has even

representations from the parliament and the

provinces and has attained a significant role in

formulation and regulation of policies for all

the subjects including health after the

abolition of the Ministry of Health. The federal

government can only legislate on the subjects

in second part of federal list after consultations

with the provincial representatives of CCI.

Subsequently, many of the functions of the

abolished MoH are now delegated to eight

institutional settings in the capital and service

delivery entirely to the provinces. The entities

taking on MoH functions at the capital level

are Economic Affairs Division, Cabinet Division,

Planning & Development, Ministry of Inter-

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The commitment to achieve the health related and coordination of health related subjects

Millennium Development Goals becomes even such as international relationship, national

more challenging with the abolition of the health information and reporting mechanisms,

federal MoH, leaving many areas vacant, financial forecasting and donor coordination.

where federal role is still very crucial. The fragmented functions and distributed

Nonetheless, devolution of health sector poses coordination activities assigned to various

many questions in terms of the capacity of institutions and provincial departments is

provinces for health planning and regulation of challenge for the provinces, where minimal

policies, strategic directions and leadership, coordination among institutional settings shall

health information generation, human be overseen. Another challenge for the

resource development and international provinces is creation of good administration

agreements. Current institutional and fair governance in their health systems.

arrangements pose health system challenges Local Government Ordinance 2001 aimed at

and constraints, as various functions and improving health system responsiveness

departments related to health have been according to local needs through participatory

devolved, merged or retained. decision making and more accountability to

public. However, weak political support and

fragile capacity of the local governments could The WHO framework on building blocks of

not institutionalize and govern health systems. health system would be analyzed to catalogue

The weaknesses such as stewardship role and challenges and constraints in wake of recent

leadership at the provincial level should not be health reforms. These are notably the

overlooked in this interim transitional phase. governance, service delivery, health

information, financing, human resources and

medical products/technologies.

A successful reform brings transition of health

programs in such a way that healthcare

delivery should not suffer. The financial Adequate health policy framework, which set

backlash of transferring the federal vertical norms and standards, has been the missing

program was not worked out for each link in health system of Pakistan. At present,

province. The transfer of additional programs government has no national health policy. A

and activities to provinces was sudden, with draft version of National Health Policy 2009

nominal interim technical guidance from was prepared but could not be approved due

federation. As a result vertical programs are to very recent organizational reforms. These

facing issues of fiscal support from their reforms now put added responsibility on four

respective health department in each provinces of Pakistan to seek policy guidance

province. Lack of ownership by the provincial in order to develop their own health

governments to support vertical programs can strategies. Only two province, Khyber

have serious implications on availability, Pakhtunkhwa and Punjab has approved health

affordability and accessibility of health strategy as opposed to other provinces which

commodities and services. are currently developing respective strategies.

Inter provincial harmonization on national

health policy development is missing and can Majority of national service delivery programs

be advocated through the forum of CCI. are channels for mobilization of donor

resources. The present challenge for these

vertical programs and their respective health Post 18th amendment, there is absence of

departments is consideration of inter- federal regulatory authority for the regulation

b) Service delivery

a) Governance

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Challenges

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provincial harmonization, contractual The abolished MoH strength was 450

agreements, resource mobilization and donor employees and other functionaries serving in

preferences in order to practice one window federal institutions. With the effect of

operation with donor organizations. An devolution, provinces have to absorb this

example to cope with this challenge is Global additional human resource which puts extra

Fund to fight AIDS, Tuberculosis and Malaria burden on fiscal capacity of provinces. In

(GFATM) which is retained in federation to addition, concerns regarding service structure

support three vertical programs under and protection of medical and paramedical

contractual agreements. staff are immediate repercussions of 18th

amendment. Very recently, frequent strikes by

the young doctors of Pakistan on their service

structure issues have become a serious affair

Institutional capacity to address public health for the provincial health departments.

emergencies and disease security is strongly

dependent on collated information system,

where prime purpose is to collect, collate,

analyze and disseminate information for NFC will remain responsibility of federal

evidence based policy and practice. Most government after 18th amendment. However,

important challenge for Pakistan in the post there is increase financial share of provinces in

devolution scenario is lack of integrated the 7th NFC award. The total health allocations

disease surveillance system and lack of inter- of provinces have been increased up to 40%

provincial information sharing mechanisms. during last two years. Due to weakly planned

There is likelihood that tools and indicators to process of recent reforms, swift transfer of

measure and monitor health may vary across financial resources to provincial vertical

provinces. programs has not occurred. As a result, vertical

health programs are facing issues regarding

fiscal support. In such situation, there is limited utilization of

the information and evidence for planning in

national programs, assessment of health It is noteworthy that no performance

services and surveillance in cases of disease parameter due to lack of collated information

security. Absence of collated provincial system was used to augment financial share

information system and irregular reporting for provinces. Similarly, resource tracking

mechanisms from health facilities are key through national health accounts is crucial for

constraints in informed decision making by any health system to monitor flow of financial

provincial stakeholders and coherent resource resources. Better performance and

allocation for priority interventions. responsiveness of health system could not be

achieved due to lack of information on health

spending in Pakistan. Compilation of provincial

health accounts is key challenge in wake of

Lack of trained staff is a chronic issue for recent reforms to prioritize expenditures and

under-utilization of primary health care increase own revenues.

services in Pakistan. So, far provinces have

failed to address inadequacies and mal-The contribution of GDP to health in Pakistan is distribution of human resource that is 0.25%, which is insufficient to meet non- unevenly deployed in urban and rural settings. development expenditures of vertical health At this point in time provinces have to develop program. To promote essential healthcare human resource information system for the packages through universal coverage, purpose of future human resource (HR) countries have to allocate WHO target of 5% requirements.

c) Health Information

e) Health Financing

d) Human Resource

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GDP expenditure on health. Provincial more rampant in public sector of developing

governments with elevated financial shares countries with regards to overpayments for

need to strategize reallocation of respective medicines and technologies. A central control

health expenditures. In the absence of for drug regulation is a significant implication

national health accounts, it would be a test for of the 18th amendment.

the provinces to reset priorities for primary,

secondary and tertiary care services. Mix of One of the key factors for under-utilization of

public-private health system in Pakistan has public healthcare systems is unavailability of

promoted out of pocket payments which put drugs. Lack of Logistic Management

financial risk on households. Insurance Information Systems (LMIS) is another strong

mechanisms such as social health insurance contributor for lack of drugs at public health

for the formal sector and social protection facilities. Very recently, planning and

strategies for the informal sector are direly development department has effectively

needed to attain universal coverage. Provincial coordinated between donor organization and

governments are facing challenge of outlining provincial health departments to ensure

pro poor strategies in this transitional phase of availability of contraceptive commodities to

reforms to protect poor from catastrophic the end mile. Such interim arrangements for

expenditures. availability of other essential health care

packages and development of LMIS are critical

challenges for provincial health departments

for uninterrupted supply of health The functions retained at Federal level commodities to primary health care facilities. Regulatory Authority are standardization and

manufacture of pharmaceutical products,

regulation of drugs and administrative control

of respective institutes. Centralized authority is

very crucial to maintain quality, price and

administration of drugs and medical supplies.

There is growing evidence that corruption is

f) Medical Products/Technologies

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1. Punjab æFocus and strengthen MNCH, family

planning and nutrition services at all levels The Department of Health Punjab is as part of EPHS.strategizing to:

æStrengthen prevention and management of æInstitute Essential Health Services Package communicable and non-communicable (EHSP) for primary (including facility-based diseases.and outreach services), secondary and

tertiary level healthcare facilities. æIntegrate preventive healthcare (vertical)

program which have common objectives.æEstablish district health complexes which

will provide oversight to rural as well as æImplement Minimum Service Delivery

urban primary health care. Standards (MSDS) and standardize services

in the hospitals.æEnsure free of cost, level-specific, 24/7,

quality emergency services at all levels of æRestructure the entire department for a

care. robust stewardship and monitoring role.

Salient features of provincial health sector strategies

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æOptimize decentralization to districts and æImplement a MHSP to be provided by all

autonomy to health facilities. primary health care units and outreach

services e.g. BHUs, RHCs, LHWs, CMWs, EPI æFully operationalize the Punjab Health technicians. Commission and Health Sector Reforms

Program. æImplement necessary training e.g.

Integrated Management of Neonatal and æEstablish a Human Resource Planning and Childhood Illnesses (IMNCI) training at all Development Unit.levels of the public health care system. and

æFill all vacant posts of healthcare providers support the training of private providers.

at primary and secondary healthcare æUpgrade health facilities on the basis of facilities, especially in rural and hard-to-

need and according to criteria established reach areas.by the DoH.

æDevelop a Provincial Health Services æAllocate resources according to incidence Academy (PHSA) on the lines of Civil

and prevalence of diseases, cost Services Academy for trainings of different effectiveness of a programme/ policy, and categories of health workers.poverty levels.

æStrengthen community based information æImprove estimates on incidence and system and its integration with facility-

prevalence of diseases with analysis based based health information system.on surveillance systems, surveys and from

æLink tertiary care and the private sector the DHIS and on poverty levels.

health facilities with district and provincial æRevitalize the delivery of family planning level information systems.

services in the public sector health facilities æEstablish a comprehensive integrated

with a mechanism for forecasting the Disease Surveillance System at provincial

contraceptive requirements.and district level.

æPilot tele-health to support provision of æOrganize, analyze and publish pertinent

specialized care to the poor in remote areas health information on health sector

of the province.performance for a wider dissemination.

æAnalyse existing services in terms of safety æStrengthen health research in both public

nets or free services to the poor community and private sector.

and develop a feasible proposal with the

æEnhance existing logistics and supply chain primary objective of reducing out of pocket

management system and regular review of expenditures.

EDL.æDevelop an emergency response

æIncrease overall government expenditure mechanism with close inter-sectoral

on health care especially for the primary linkages and implemented to cover

level. emergencies, epidemics and disasters at

the provincial and district levels.æIntroduce mechanisms of social safety nets

such as health voucher schemes for æEstablish trauma care and burn units at

protecting poor from health shocks. divisional level hospitals and develop

linkages with 1122 for the provision of pre-æIncrease budget utilization rate at the hospital care services.provincial and district governments.

æDevelop a comprehensive Mental Health

Strategy and ensure establishment of

institutions for rehabilitation of mental The Department of Health Khyber patients.Pakhtunkhwa is strategizing to:

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æStrengthen the Personnel section at DoH to building in evidence based interventions.

perform all human resource management æRe-define links with PWD with shift of functions. contraceptive services through district and

æDevelop a continuing medical education urban PHC systems and aimed at birth

program for all medical, nursing and spacing in younger couples.

paramedical staff linked to career æEnhance sector-wide access to essential development. drugs through improvement in quality

æReview of stewardship function of DoH by assurance, affordability, supply

re-aligning its functions of policy management and rational prescriptions.

development, planning, reforms, æRegulate the health sector in particular the monitoring and evaluation etc. extensive private sector towards licensed

æIntegrate all national programmes practice, standardization of care, minimal

information systems into the DHIS and reporting requirements and address of

establish functional linkages between all medical negligence.

levels of operation (facilities, district, æIncrease investment in health sector and provincial or federal management). shift towards innovative financing systems

æImplement the policy for the development to reduce OOP expenditure in the poor.

of a health management cadre. æPilot inter-sectoral district based projects on

æDevelop a health financing policy with nutrition and social development through

objectives of promoting social health collaboration with BISP, water & sanitation,

protection and reducing OOP expenditure. education and other sectors.

æDevelop a trained administrative cadre to

improve efficiency of health administration.

æDevelop a hospital pharmacy cadre to The Department of Health Sindh is strategizing ensure rational use of drugs and quality tomanagement of inventory.

æStrengthen district health systems starting æEnhance accountability for medical with most under-developed districts of

negligence and consumer support Sindh.mechanisms.

æImplement an Urban PHC system built on æEstablish hospital autonomy pilots for major public private partnerships and addressing

tertiary hospitals while building in social contextual needs of low income urban accountability and transparency and pro-population.poor protection measures.

æEstablish Comprehensive Health Centers

offering EPHS in each district.

æContract out facilities in remote talukas of

disadvantaged districts to qualified private The Department of Health Balochistan is

sector entities for publically financed unfortunately lagging behind in terms of

provision of MSDP. embarking upon the exercise of developing a

5 years strategy for its health sector. Donor's æStreamline human resource production, assistance is there and the team of retention and capacity to support priority consultants is about to be finalized. heath needs.

æFunctionalize MNCH services at ESDP, MSDP

and community based level and Nonetheless, DoH Balochistan is well

enhancement of community based services cognizant of the issues and challenges

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confronted in the wake of law and order and from secondary to tertiary healthcare level.

political instability in the province. Looking at æTo improve the immunization coverage the PDHS 2006-07, NNS 2011, PSLSM 2011, it among the women and children population is quite evident that Balochistan as a province across the state of AJK.has grossly under performed in terms of all

æTo increase the proportion of deliveries health indicators, nutrition status, and socio-

attended by the skilled birth attendants.economic parameters. Maternal mortality ratio

æTo reduce the unmet need for family is one of the highest not only in the country

planning by introducing integrated and but in the region (785/100,000 live births).

sector wide approaches to address the More than 56% women do not get any

issue.supplementation during the pregnancy.

Contraceptive prevalence rate is the lowest in æTo reduce the number of miscarriages by the whole country (14%). Only 41% women instituting operational research across the seek antenatal care, out of which barely 23% state of AJK and re-orienting the maternal deliver at a health facility. Children with full health services accordingly.vaccination coverage are 35% which is again

æTo re-align the MNCH strategies and lowest in terms of program coverage. One

activities in the light of findings of AJK-DHS third of the children do not receive any

2010.vaccination at all. For half of the children in

æTo ascertain the burden of disease due to Balochistan, no treatment is sought for ARI NCDs by instituting hospital-based and and diarrhea. Around 32% children are stunted participatory research with communities or severely malnourished. across the state of AJK and re-orienting the

services accordingly.Moreover, being an under-developed province

æStreamline the collaboration of DoH with with scarcity of financial, technical and human

PPHI enlisting clear roles & responsibilities resources, it is quite logical to predict that

with mutually agreed deliverables & Balochistan will be able to map out more or

performance targets.less same system's related issues, perhaps

æTo formulate and implement a with more gravity. Thus the need would be to comprehensive SRH policy for production, have the most workable health sector strategy management, retention and motivation of for the province, which would be owned by health personnel to serve the population of the DoH and would assist the provincial AJK.decision makers to re-orient the health system

in the best interest of the marginalized people æTo revisit HRIS and implement as a decision of Balochistan. making tool for addressing the HR issues.

æTo implement, operationalize and

strengthen the DHIS in all the 10 districts of

AJK.The Department of Health AJK is strategizing

æTo establish a DHIS unit at the level of to:DGHS office for consolidation of the

æImplement a costed essential service information and reports generation.

package both at primary and secondary æTo revisit the scope and content of the DHIS healthcare level.

so as to integrate data from LHW, MNCH æImplement MSDS both at primary and

and DEWS etc.secondary healthcare levels of public sector

æTo improve logistic and supply chain as well as in the private sector.management system for regular,

æInstitutionalize an operational referral uninterrupted and adequate availability of

system from primary to secondary and

5. Azad Jammu & Kashmir

11



12

essential drugs at all levels of health care Academy for instituting in-service training

of all cadres of health personnel in the æTo establish a procurement and logistic cell DoH. at the state level and to implement PPRA

rules and regulation for public sector drugs æTo foster a meaningful collaboration with

procurement. NGOs, private sector and development

partners for taking initiatives towards æTo implement and revisit EDL for all levels health system strengthening. of health care according to the burden of

diseases of the population served.

æTo operationalize the DTL for enforcing and

improving the manufacturing standards for The Department of Health GB is strategizing drug companies. to:

æTo implement an integrated budgetary æStrengthen the stewardship role of the

planning process whereby DoH has the department in the context of new roles and mainrole in consultation with Finance and challenges faced by the department.Planning Departments.

æEstablish a Policy Planning unit at provincial æTo align the donor funding with DoH level and staff it with competent

strategy and priority areas for investment. professionals after competitive selection.

æTo introduce social health insurance and æEnsure the representation of the community

other safety nets protecting the in the Policy & Planning processes by disadvantaged and vulnerable from ensuring their membership in the relevant catastrophic health expenditures bodies.

æTo enhance the efficiency of public æDevelop the Human Resource policy

spending by re-orienting certain budget framework to enhance the quality and heads and re-costing of certain entities, productivity of work force.thus improving budgetary utilization.

æDevelop and implement HRIS optimally to æTo explore private sector participation in ensure transparency of the processes and

provision of publically provided health timely decision making, based on evidence.services by outsourcing through transparent

æDevelop a costed MHSP to ensure the competitive process.

uniform implementation of health services.æTo establish an autonomous health

æIncrease coverage and utilization of quality regulatory authority for ensuring standards

services at primary & secondary health care in service delivery, drugs regulation, human

levels by implementing MHSP.resource production and accreditation etc.

æIntroduce quality assurance mechanism to æTo decentralize the management in DoH to

ensure safety of patient / client.divisional and district level for improved

æDevelop regulatory framework both for efficiency and responsiveness in the service

public and private sector to ensure good delivery.

quality /optimal services.æTo integrate or merge health and

æEnsure implementation of District Health population departments for resource saving

Information System and allocate adequate and streamlining the activities pertaining to

resources for DHIS through regular budgetreproductive health.

æIntegrate different information systems and æTo revitalize IPAP to take up the role of

produce consolidated annual report for HSRU for overseeing the proposed and

evidence based decision making.future reforms across the health sector.

æImprove availability of quality essential æTo establish a Provincial Health Services

6. Gilgit-Baltistan

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medicines in health facilities based on æDevelop a risk pool system based on a mix

standardized services at each level. of general revenue/social insurance/out-of-

pocket payments.æReview and formulate essential drug list

based on population need and æIntroduce Voucher Scheme and SHI in

standardized services for each level of collaboration with private health sector to

services assist identified beneficiaries.

æStrengthen the existing revenue generation æEnsure functional parliamentary health

system to raise sufficient and sustainable committees conducting regular performance

funds through efficient means to provide review and facilitate the Health department

essential health services to the public. in implementation.

æEstablish a disease surveillance system by

integrating information from both public

and private health facilities.

13

Health Systems & Policy Implications after DevolutionThe optimistic view

The down side

culminate into a higher level of ownership by

the respective provincial stakeholders.Some of the important positive sides of

devolution are worth discussing at this d) Having participated, approved and owned

juncture. The provinces have been the strategies for health sector in the

constitutionally granted the autonomy which provinces, now a great deal of responsibility

they had always envied in the light of original lies with the provincial health authorities to

constitution of 1973 of Islamic Republic of roll out these strategies in the best possible

Pakistan. Having this level of autonomy, the and viable manner. Only a realistic and timely

provinces are now free to strategize, plan and operationalization of the strategies will bear

act for the improvement of their respective fruits i.e. improved health outcomes of the

health sectors; and that also in their own local most vulnerable populations who have been

context. devoid of essential and basic healthcare at

their doorsteps for years.a) Provinces are now the stewards of their

health systems to provide vision, roadmap and e) All the strategies have been asked to

framework for steering the health affairs of follow the WHO's health systems

their respective populations. strengthening building blocks which provide a

uniform framework for benchmarking as well b) The health sector strategies which are as carrying out a comparative analysis at some being developed with the donors' assistance point in time. in each of the provinces are more relevant and

context based on a fresh, sound and thorough

situation analysis conducted in each of the

area; 4 provinces, AJK and GB. Looking at the down side and a bit of

c) Since these strategies and roadmaps are pessimistic view point, the whole process of being developed in a process of exhaustive devolution suffered from a knee jerk reaction consultations with the provincial departments of the provincial governments who claimed of health, other line departments, P&D, and unprepared, incapacitated and perhaps also other stakeholders in non-government arena, unaware of the actual implications of the it is envisaged that this will eventually devolution. Other schools of thought outside



the health departments also worried about between the units. One unit lacking capacity,

the future of this reform and to some extent human resource, financing, technical expertise

these concerns have got the substance. could have benefitted from the one having all

the paraphernalia. Who will be the moderator

now for fostering such a relationship between a) An integrated and unified vision for health

the provinces? That is the question.for all was the prime responsibility of the

d) Donors and development partners are still central government which is now questioned in the state of ambiguity. Their preference is to as to who will ensure that the entire nation deal with one window. However, after has a common vision and a cohesive mission. devolution, this may not be the case and they Would every province and area be having a will have to interact with multiple windows different vision, strategy and goals for the across the country. Donors will be more health of their people? Is there still a role of strategic and choosy in terms of investing and the federation in this regard?that will be primarily based on their

b) Regulation & standardization was yet convenience to work with certain provinces

another responsibility of the federation which and not to work with others. Federal

ideally lies with the provinces now. Medical government or a central authority was in a

education, service delivery, skills and position to redirect donors' money where

qualifications, quality of drugs, licensing and there was a felt need and priority investment

accreditation were some of the matters which was required.

would need attention of the provincial DOHs

and of course they would not have the

required level of capacity and expertise.

c) Inter-provincial harmony is often needed.

Federal government was in a position to

moderate such conducive relationship

Key strategies for health systems strengtheningCome what may, there is a global consensus financed and managed by the Federal Ministry

on some key strategies which the developing of Health before the devolution. These

countries must adopt in order to strengthen included National Program for Family Planning

their health systems. These strategies or & Primary Health Care (LHW program),

actions seem very pertinent to the current Maternal, Newborn and Child Health, Hepatitis

scenario of health system of Pakistan and Control, Expanded Program for Immunization,

therefore must be considered very Tuberculosis control, Roll Back Malaria,

thoughtfully for the sake of making our HIV/AIDS Control etc. These programs have

system responsive to needs of the people of delivered reasonable results. Therefore, the

Pakistan. provinces will have to strategize how to

integrate and wisely manage the vertical

programs (financing, human resources) in

order to reach out to the people without any

interruptions or decline in the performance.

By and large, the health care delivery was For this challenge, it would be essential to

with the provinces (the sub-national units) build capacity of the human resource,

except the vertical programs which were revitalize the primary health care and

a) Building capacity of health system to

deliver

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adequately finance all the services: governance issues that are responsible for the

preventive, curative and promotive at the poor health services not only in the public

district level. Perhaps, a meaningful domain but also in the private sector.

partnership with NGOs, who have a sound Institutional mechanisms for strategic health

track record of technical work in this regard, planning, regulation and standard setting, fair

can also be considered. NGOs can also be financing and credible audit, health

instrumental in filling in the gaps in service information and its use, human resource

delivery where government feels development and distribution, and disease

incapacitated to reach out and deliver. surveillance need to be strengthened at the

provincial level now. Engagement of the civil

society organizations at the provincial level

and the communities' representatives at the

Traditionally, split of non-development budget district level can bring in an element of

has been bigger than the development transparency in the functioning of the health

budget. Furthermore, in the post 18th system.

amendment scenario, additional human

resource transferred to the provinces will have

to be catered for their salaries and benefits.

Provincial health departments have to be Out-of-pocket health spending by households

vigilant enough to allocate a justified amount accounts for more than half of total health

to the development side of the health too. financing in most developing countries in Asia;

Role of donors, development partners, NGOs, and more than 65% in Pakistan. While seeking

philanthropists and private sector must be health care in the private sector (utilized by

reviewed rationally and considered for 80% people for first level care), almost 92%

ensuring the sustainability in the health sector goes out of pocket. Reducing OOP payments

operations. Before launching new projects and and developing appropriate financial risk

new interventions, it would be imperative to protection systems is crucial to increasing

carry out value-for-money analyses. As a access to health care by the poor and working

matter of fact, this means formulating right towards the goal of universal coverage.

methodologies for estimating costs at the Provincial governments may not be ready at

level of service delivery and designing this point in time to embark upon the venture

instinctive ways to look at these costs and use of social health insurance. However, other

them to improve the efficiency of service mechanisms of social protection and safety

delivery system. nets must be tried out. These include

conditional cash transfers, prepaid vouchers

and community based health insurance and

financing. Provinces will have to increase the

Good governance aims to improve the quality health sector allocation by 50% every year for

of essential health services. Health system in the next 10 years to attain a respectable set of

Pakistan has been confronted with all levels health indicators. This can only happen if the

and types of corruption impeding the quality provinces consolidate the expenditure

service delivery and severely affecting the information and develop the coordinating

health outcomes. These reforms are a critical mechanisms that can oversee progress on

step and needed to bring rapid improvements planning strategic and long-term investments,

in health services at the point of delivery. At introducing pro-poor health reforms and

the same time, there is a need to review and making the basic analyses on strategic choices

reform the organization and functioning of the and financing options. Rising poverty and

provincial department of health and district uncontrolled inflation in the country

health offices to address some of the core necessitate steps to protect the poor from

b) Balancing cost and sustainability

d) Protecting people from financial risks

c) Improving health governance

19,29

30

31

32



incurring catastrophic expenditures on health, subsidize the costs of a package of

which is a basic human right. reproductive health care services and

transportation for the poor women. It has

shown to reduce maternal and infant mortality

by increasing utilization of antenatal care,

skilled delivery, and postnatal care, as well as

Conventionally, provinces have never been family planning services. In recent years, the

awarded the share of resources from the primary health care facilities have been

federal government based on any contracted to non-state entities. No doubt this

performance parameters. As a consequence, endeavor has shown tremendous

the districts too were funded based on improvement in various aspects of service

incremental budgets. For determining the delivery at a level and in circumstances where

performance of a health system, be it the government has struggled for years. Since

provincial or at district level, there has to be a provincial governments would be the forefront

robust information system which would financier of health, scaling up of this

furnish data on expenditures, allocative contracting initiative should also be linked

efficiency, human resource, disease burden with pre-determined set of indicators and

etc. In the post devolution times, all the targets to achieve the best results and

provinces must strategize to develop and maximum benefit for the population to be

organize a Health Systems Database which served.

would allow users to easily compile and

analyze provincial and district level data to

quickly assess the performance of a district

health system, benchmark district's

performance against others and monitor Resource tracking monitors the flow of

progress toward system strengthening goals. financial resources within the health sector.

Simultaneously, it would be worthwhile that Governments as well as the development

provinces develop mechanisms to keep an partners depend on health expenditure data to

eye on the responsiveness of the health appraise past performance of health programs

services that is a reflection of direct and thereon guide the decision-making.

satisfaction of its users. Pakistan government has not been able to

compute National Health Accounts (NHA) on

regular basis. Nevertheless, two reports were

compiled for year 2005-06 and then 2007-08.

To what extent the information was used for

Pay for performance is a strategy to link decision making, remains questionable.

payments and incentive to a set of targets to Pakistan represents a health sector where

be achieved. This approach has shown to government's share in health spending is

improve the use of health services, and barely US$ 4-6 per capita, out of pocket

improve the quality and availability of those expense is heavy, donors' contribution is

services. For the provinces, who would want unpredictable and private sector's expenditure

to be more strategic in terms of spending their is growing day by day, owing to escalating

money, pay for performance approach can be cost of quality health care. A costed health

adopted for the districts against the results sector strategy could be the only solution to

delivered as well as with the hospitals by ascertain the essential health service package

giving them specific targets. In Pakistan, pay at primary and secondary health care levels

for performance has been experimented which are under provincial control now. This is

through supply-side payments to the health crucial to achieve the WHO target of 5% GDP

providers and demand-side vouchers that expenditure on health and of Commission on

e) Measuring and monitoring health

system's performance

g) Tracking expenditures through health

systems

f) Paying for results to improve health

system's performance

Ap

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33

34

35

36

37 38

17

Macroeconomics and Health to secure and PHC centers because they do not find the

universal coverage to an essential package of enabling environment and conducive working

health services. In the post devolution times, conditions. In search of better civic amenities,

the provinces will require a comprehensive majority of the health care workers settle

health spending information, perhaps by down for an employment or establish their

establishing their respective NHAs, which will practices in urban centers of Pakistan. At one

inform the policy making processes for point in time, there were only 25% of PHC

resource mobilization, pooling and allocation facilities with a female health care provider.

in the years to come. After contracting PHC services, situation is

improving slowly. Doctor-patient ratio and

doctor-nurse ratio is far below the

international standards. In this regard, it is

critical for the provinces to develop a human

Primary health care has been grossly under- resource information system and use it for

utilized in Pakistan. Besides numerous other future HR requirements. Medical, dental,

issues, lack of trained human resource is a nursing and paramedics schools should be

chronic issue. One, there are not enough established according to the need of the

personnel trained; second, those who are health departments.

trained do not want to serve the rural areas

h) Allocating human resources to health

system

Opportunities & Way forwardFirst and the foremost step in the current existing. This is a high time for lobbying for

scenario of transition would be to educate instituting appropriate checks and balances to

ourselves, educate the partners, educate the curb the corruption across the health sector

communities and all other stakeholders. and to ensure a fair degree of transparency. In

Keeping oneself well informed of the these times of gradual transition, there is a

constitutional amendment and new provisions clearly felt need for institutional strengthening

would be worthwhile. It is quite evident now and capacity building at the provincial level,

that in the new arrangement, it is imperative mainly for ensuring a responsive service

to interact closely with provinces, and least delivery with continuity and quality. Lastly, all

with the federal tier of government, except in criticism apart, the matter of the fact is that

few cases and instances where certain this devolution is a window of opportunity to

domains still lie with the center. This will be a re-orient the entire health system of the

very pragmatic approach to embark upon an country bringing in the most crucial yet

action oriented advocacy for plugging the overarching element of good governance.

gaps in the health system, previous as well as

AcknowledgementsThe author thanks LEAD Pakistan for make use of it while rolling out their

sponsoring this strategic paper for the sake of respective health sector strategic plans.

assisting all the provincial governments to

39 40

10



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