DEVOLUTION PLAN AND DEVOLUTION PLAN AND HEALTH CARE IN PAKISTANHEALTH CARE IN PAKISTAN

CHALLENGES AND CONSTRAINTSCHALLENGES AND CONSTRAINTS

Dr. Babar T. ShaikhDr. Babar T. Shaikh

The Aga Khan University, Karachi, Pakistan.The Aga Khan University, Karachi, Pakistan.

VISIONVISION • Health is a basic human right and must be Health is a basic human right and must be

available and accessible in an affordable available and accessible in an affordable framework to all. To this end, an integrated framework to all. To this end, an integrated approach to public health in the district will approach to public health in the district will combine preventive, promotive and curative combine preventive, promotive and curative health at all levels. Reductions in demand of health at all levels. Reductions in demand of curative care, would be translated into curative care, would be translated into improvements in its quality. improvements in its quality.

• Promoting good governance in health sector, by Promoting good governance in health sector, by meaningful and consistent emphasis on prompt, meaningful and consistent emphasis on prompt, equitable and professional services delivery, must equitable and professional services delivery, must become a cardinal principle of the department. become a cardinal principle of the department.

Devolution, Decentralization, Devolution, Decentralization, DebundlingDebundling

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

Main Objective: Main Objective:

philosophical & ideologicalphilosophical & ideological

Providing the means for community Providing the means for community participation and local self-reliance and participation and local self-reliance and ensuring the accountability of ensuring the accountability of government officials to the population.government officials to the population.

DEVOLUTION OF POWERS IN DEVOLUTION OF POWERS IN HEALTH DEPARTMENTHEALTH DEPARTMENT

OBJECTIVESOBJECTIVES• Empowerment of the people at the grass Empowerment of the people at the grass

root level.root level.

• To make the District the dominant level of To make the District the dominant level of decision making in health department.decision making in health department.

• Improve the quantity and quality of health care Improve the quantity and quality of health care delivery to the people close to their door steps.delivery to the people close to their door steps.

• Integrated approach to public health, Integrated approach to public health, combining, preventive, promotive and curative combining, preventive, promotive and curative health at all levels.health at all levels.

RESPONSIBILITIES/ FUNCTIONS RESPONSIBILITIES/ FUNCTIONS AT THE DISTRICT LEVELAT THE DISTRICT LEVEL

• Prevent and Control Communicable Prevent and Control Communicable Diseases and Non Communicable Diseases.Diseases and Non Communicable Diseases.

• Food Sanitation.Food Sanitation.

• Maintain medical and health statistics Maintain medical and health statistics under HMIS.under HMIS.

• Reproductive Health.Reproductive Health.

• Health and Nutrition Education.Health and Nutrition Education.

• Environmental and Occupational Health.Environmental and Occupational Health.

RESPONSIBILITIES/ FUNCTIONS RESPONSIBILITIES/ FUNCTIONS AT THE PROVINCIAL LEVELAT 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 Monitoring and Regulatory functions of Medical and Para Medical institutions. Medical and Para Medical institutions.

• Health Research and related Health Health Research and related Health information gathering.information gathering.

RESOURCE/ASSETS DISTRIBUTION RESOURCE/ASSETS DISTRIBUTION FOR THE DISTRICTFOR 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] HospitalsType-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.

PROGRESS SO FARPROGRESS SO FAR • Posts in Directorate General of Health Services Posts in Directorate General of Health Services

have been re-designatedhave been re-designated

• Budgets according to the new requirements.Budgets according to the new requirements.

• All DHOs and ADHOs have been briefed by the All DHOs and ADHOs have been briefed by the department twice on its approved Devolution plan.department twice on its approved Devolution plan.

• Briefing was held for both DHOs and DCs of all Briefing was held for both DHOs and DCs of all districts by Health Departmentdistricts by Health Department

• All DHOs have been instructed to work as a team All DHOs have been instructed to work as a team with the DCs at the district levelwith the DCs at the district level

• All DHOs have been asked to develop lists of their All DHOs have been asked to develop lists of their assets for distributionassets for distribution

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: ADMINISTRATIVE STRUCTURE:

FUNCTIONS OF FUNCTIONS OF

EXECUTIVE DISTRICT OFFICER EXECUTIVE DISTRICT OFFICER • Ensure that the business of the department Ensure that the business of the department and offices placed under his administrative and offices placed under his administrative control is carried out in accordance with the control is carried out in accordance with the relevant laws and rules. relevant laws and rules.

• Co-ordinate and supervise the activities of the Co-ordinate and supervise the activities of the relevant offices.relevant offices.

• Ensure efficient services delivery by Ensure efficient services delivery by functionaries under his control.functionaries under his control.

DISTRICT HEALTH MANAGEMENT TEAMDISTRICT HEALTH MANAGEMENT TEAM

What is the purpose of a DHMT ?What is the purpose of a DHMT ?

Develop a Team approachDevelop a Team approach

Share and Exchange ViewsShare and Exchange Views

Reduce the workload of the DHOReduce the workload of the DHO

Optimize Utilization of the Human Optimize Utilization of the Human ResourcesResources

Improve Cooperation and Collaboration Improve Cooperation and Collaboration among stakeholdersamong stakeholders

How is a DHMT Constituted ?How is a DHMT Constituted ?

        DHODHO

         Other District ManagersOther District Managers

         Public Sector Health Care ProvidersPublic Sector Health Care Providers

        Private Sector Health Care ProvidersPrivate Sector Health Care Providers

Community or its elected leadersCommunity or its elected leaders

Role of DHMTRole of DHMT

Sharing of experiences and exchanging of Sharing of experiences and exchanging of views & ideas.views & ideas.

Taking responsibilities and improving Taking responsibilities and improving technical efficiency by supporting, technical efficiency by supporting, assisting.assisting.

Improve cooperation and collaboration Improve cooperation and collaboration with the Government and private health with the Government and private health related sectors.related sectors.

OUTCOMESOUTCOMES• Well-defined structures have been developed and Well-defined structures have been developed and resources allocated.resources allocated.

• Meaningful partnerships at provincial, district, Meaningful partnerships at provincial, district, tehsil and community level, through the tehsil and community level, through the establishment of DHMT,THMT and citizen boards.establishment of DHMT,THMT and citizen boards.

• Detailed mapping of resources and services need to Detailed mapping of resources and services need to be developed.be developed.

• In planning and implementation of program a In planning and implementation of program a right based and integrated approach needs to be right based and integrated approach needs to be developed.developed.

• Meaningful action and capacity building would be Meaningful action and capacity building would be required at all levels.required at all levels.

HEALTH EXPENDITURE HEALTH EXPENDITURE SITUATION AT PRESENTSITUATION AT PRESENT

• Almost 100% is out-of pocketAlmost 100% is out-of pocket

• Includes formal and informal private sector Includes formal and informal private sector

• Questionable quality of careQuestionable quality of care

• Considerable expenditures on unnecessary and Considerable expenditures on unnecessary and

inappropriate (sometimes unsafe) careinappropriate (sometimes unsafe) care

• Inequity in financing of careInequity in financing of care

• No regulation or standards on fee charged No regulation or standards on fee charged

• Reliable information not availableReliable information not available

ADVANTAGES OF DEVOLVED ADVANTAGES OF DEVOLVED SYSTEM IN HEALTH CARESYSTEM IN HEALTH CARE

• Administrative and financial powers to Administrative and financial powers to district authorities / local bodies district authorities / local bodies representative.representative.

• Involvement in devising the programs Involvement in devising the programs relevant to the local needs and priorities.relevant to the local needs and priorities.

• Strategies and plans acceptable for the Strategies and plans acceptable for the community and matching to their socio community and matching to their socio cultural and socio economic background.cultural and socio economic background.

• User willingness to pay for PHC in the User willingness to pay for PHC in the public sector services, public sector services, ifif they receive they receive improved care.improved care.

• The districts can recover substantial costs The districts can recover substantial costs and can retain the incomes.and can retain the incomes.

• Creating sense of ownership.Creating sense of ownership.

• Strengthening of FLCF, answering many Strengthening of FLCF, answering many primary health problems like high IMR, primary health problems like high IMR, high MMR and morbidity and male high MMR and morbidity and male involvement. involvement.

CRITERIA FOR ALLOCATING CRITERIA FOR ALLOCATING DISTRICT BUDGETSDISTRICT BUDGETS

• Population SizePopulation Size

• Socio-economic Development Socio-economic Development

• Health InfrastructureHealth Infrastructure

• Health Needs / Problems (BOD Estimation)Health Needs / Problems (BOD Estimation)

• Performance Evaluation based on Performance Evaluation based on

predetermined indicatorspredetermined indicators

• Combination of AboveCombination of Above

CHALLENGES AND CHALLENGES AND CONSTRAINTSCONSTRAINTS

• Political willingness of provincial and district Political willingness of provincial and district governments to work in the new system.governments to work in the new system.

• Defining their administrative roles with Defining their administrative roles with limits and jurisdiction.limits and jurisdiction.

• Distribution of financial powers between Distribution of financial powers between Provincial and District representatives. Provincial and District representatives. (dependency of districts on provinces for (dependency of districts on provinces for how long?)how long?)

• Financial and administrative capacity of Financial and administrative capacity of the district government.the district government.

• Resentment against the status quo at the Resentment against the status quo at the provincial level and fear of loosing provincial level and fear of loosing authority.authority.

• Lack of trust and losing the profit.Lack of trust and losing the profit.

• Status of Public Service Commission, Status of Public Service Commission, Medical colleges and Tertiary hospitals.Medical colleges and Tertiary hospitals.

THE INTERNATIONAL THE INTERNATIONAL DEVELOPMENT TARGETSDEVELOPMENT TARGETS

1. A reduction by one half in the proportion 1. A reduction by one half in the proportion of people living in extreme poverty by 2015of people living in extreme poverty by 2015

2. Demonstrated progress towards gender 2. Demonstrated progress towards gender equality and the empowerment of women equality and the empowerment of women by elimination gender disparity in primary by elimination gender disparity in primary and secondary education by 2005 and secondary education by 2005

3. A reduction by two-thirds in the mortality 3. A reduction by two-thirds in the mortality rates for infants and children under age 5 rates for infants and children under age 5 and reduction by three-fourths in maternal and reduction by three-fourths in maternal mortality - all by 2015mortality - all by 2015