Transcript Challenges and Opportunities in Health
Devolution in Health Sector
Challenges and Opportunities for Evidence based Policies by Dr. Babar Tasneem Shaikh December 14, 2012
Devolution in Pakistan: the 18 th Amendment
• Before the present devolution – Devolution in 2001 (LGO 2001) – District Health System • Under 18 th amendment – Abolition of the concurrent list – 18 ministries including health and population welfare totally devolved
Devolution in Pakistan: the 18 th Amendment
• Concurrently: – NFC Award of 2010-11 – Unprecedented share of finances and other resources transferred to provinces • However: – Unlike education, health care not a fundamental right – Progress in health indicators (MDGs 4, 5 & 6) very slow • Associated health system constraints
Pre-18 th Amendment Scenario
• Federal Ministry of Health in the driving seat • Operating through the concurrent legislative list • Managing: – Provincial health departments – Eleven vertical programs – Seven tertiary care centers – National Health MIS and other Info Systems
Post 18 th Amendment Scenario
• Provinces more empowered to operate their health systems • Ministry of Health abolished • CCI - the link between Federal & Provincial Governments • Federal Gov can only legislate on subjects in second part of Federal Legislative Lists • Some functions of MoH delegated to eight institutional settings, which are: – Ministry of Inter Provincial Coordination (IPC) – Ministry of National Regulation & Services – EAD, Cabinet Div, P&D, FBS, Capital Admin & Dev
Post-18 th Amendment Scenario
• Policy formulation and health planning devolved • Service delivery now entirely with the provinces • National HMIS replaced with District Health IS • Some programs – TB, Malaria and AIDS etc. – retained: – Under contractual agreement – With the Ministry of IPC • Drug Regulatory Authority also retained
Challenges and Constraints
• Achievement of health related MDGs – MoH abolished – Leaving many areas unattended • Issues of capacity in the provinces – at least initially - in: – Health planning and regulation of policies – Strategic directions and leadership – Health information generation – Human resource development – International agreements
Challenges and Constraints
• WHO framework on building blocks of health system – Governance – Service Delivery – Health information – Financing – Human Resources – Medical Products/Technologies
Challenges and Constraints Governance
• Absence of adequate policy framework • Absence of inter provincial harmonization on health policy development • Absence of federal regulatory authority for coordination – International relationships – National health info and reporting mechanisms – Financial forecasting – Donor coordination • Fragmented functions and distributed coordination activities • Creation of good administration and fair governance • Lessons from LGO 2001 implementation
Challenges and Constraints Service Delivery
• Financial transfer sudden and without optimal technical guidance • Vertical programs facing issues of fiscal support • Challenges of national service delivery programs – Inter-provincial harmonization – Contractual agreements – Resource mobilization – Donor preferences for one window operations
Challenges and Constraints Health Information
• Lack of integrated disease surveillance system • Lack of inter-provincial info sharing mechanisms • Absence of collated info and irregular reporting • So there is limited utilization of info and evidence for – Planning in national programs – Assessment of health services – Surveillance in case of disease security • Results in constrained decision making
Challenges and Constraints Human Resource
• Lack of trained staff resulting in – Underutilization of primary health care services • Uneven deployment in urban and rural areas • Absorption of federal staff – additional financial burden • Concerns about service structures – strikes by – Young doctors – Nurses – Paramedical staff
Challenges and Constraints Health Financing
• Provinces have up to 40% more funds, but – Weakly planned process of reforms – Slow transfer of funds, and so – Vertical health programs facing problems • No performance parameters due to lack of collated info • Poor resource tracking • Compilation of provincial health accounts is a key challenge • With only 0.25% GDP spent on health, increase in financial outlay is an imperative
Challenges and Constraints Medical Products/Technologies
• Centralized authority is required, hence retained at the federal level for – Standardization and manufacture – Regulation of drugs, and – Administrative control of institutes • Lack of drugs leading to underutilization of public healthcare • Lack of Logistic Management Info System (LMIS) leading to lack of drugs • Availability of essential health care products is the main challenge
Provincial Health Sector Strategies
• All provinces (including AJK and GB) working on them • KPK has now an approved strategy • Sindh and Punjab to follow suite • Similarly for AJK and GB • Baluchistan, with its peculiar problems, somewhat lagging behind but working on it • Salient features of these provincial strategies given in the paper • Key common features discussed in the following slides
Provincial Health Sector Strategies Governance
• Review of stewardship function of DoH by re-aligning its functions of policy development, planning, reforms, monitoring and evaluation etc.
• Establish a Policy Planning Unit at provincial level and staff it with competent professionals after competitive selection.
• Strengthen district health systems starting with most under developed districts.
• Regulate the health sector, in particular the extensive private sector towards licensed practice, standardization of care, minimal reporting requirements and address of medical negligence.
Provincial Health Sector Strategies Information System
• Integrate all national programmes’ information systems into the DHIS and establish functional linkages between all levels of operation (facilities, district, provincial or federal management).
• Revisit the scope and content of the DHIS so as to integrate data from LHW, MNCH and DEWS etc.
• Link tertiary care and the private sector health facilities with district and provincial level information systems.
Provincial Health Sector Strategies Human Resources
• Streamline human resource production, retention and capacity to support priority heath needs.
• Strengthen the personnel section at DoH to perform all human resource management functions.
• Develop a continuing medical education program for all medical, nursing and paramedical staff linked to career development.
Provincial Health Sector Strategies Drugs, Supplies & Technologies
• Improve availability of quality essential medicines in health facilities based on standardized services at each level.
• Improve logistic and supply chain management system for regular, uninterrupted and adequate availability of essential drugs at all levels of health care.
• Establish a procurement and logistic cell at the provincial level and to implement PPRA rules and regulation for public sector drugs procurement.
• Implement and revisit EDL for all levels of health care according to the burden of diseases of the population served.
Provincial Health Sector Strategies Financing
• Allocate resources according to incidence and prevalence of diseases, cost effectiveness of a programme/ policy, and poverty levels.
• Introduce safety nets to protect poor from catastrophic expenditures e.g. social health insurance, community based health insurance, vouchers.
• Implement an integrated budgetary planning process whereby DoH has the mainstay in consultation with Finance and Planning Departments.
• Align the donor funding with DoH strategy and priority areas for investment.
• Introduce social health insurance and other safety nets protecting the disadvantaged and vulnerable from catastrophic health expenditures.
Provincial Health Sector Strategies Service delivery
• Develop, cost and implement an Essential Health Service Package at Primary & Secondary levels.
• Revitalize the delivery of family planning services in the public sector health facilities.
• Institutionalize an operational referral system from primary to secondary and from secondary to tertiary healthcare level.
• Re-align the MNCH strategies and activities in the light of findings of DHS.
• Increase coverage and utilization of quality services at primary & secondary health care levels by implementing EHSP.
Health Systems & Policy Implementation Post Devolution The Optimistic View
• Provinces now free to strategize, plan and act without federal dictation.
• Able to provide vision, roadmap and framework for steering health affairs.
• Strategies being developed are more relevant and context based on fresh, sound and situation analyses.
• More intense and deeper consultation would result in greater ownership by provincial stakeholders.
• All strategies following WHO standards and building blocks with uniform framework for benchmarking.
• Participated, approved and owned strategies have the potential to transform the system.
Health Systems & Policy Implementation Post Devolution: The Down Side
• The whole process suffered from a knee jerk reaction from the provincial govts – complaints of being unprepared, incapacitated and perhaps unaware of the implications • An integrated and unified vision of health for all – – Who would ensure a common national vision and cohesive mission?
– Would every province have a different vision, strategy and goals?
– Would there still be a role of the Federal Gov in this regard?
• Regulation and standardization now also ideally lie with the provinces. How would this responsibility carried out in the future?
• What about the much needed inter-provincial harmony? Who will be the moderator between the provinces?
• Donors and development partners are still in a state of ambiguity. Wanting one-window dealing they might prefer to work with only some provinces based on their convenience
Key Strategies for Health Systems Strengthening
• Building capacity for health system to deliver • Balancing cost and sustainability • Improving health governance • Protecting people from financial risks • Measuring and monitoring health system’s performance • Paying for results to improve health system’s performance • Tracking expenditures through health systems • Allocating human resources to health systems
Opportunities and the Way Forward
• First and foremost: educate ourselves, the partners, the communities and all other stakeholders.
• It is imperative to interact closely with the provinces, and barring few areas, less with the federal tier.
• Pragmatic approach to embark upon an action oriented advocacy for plugging the gaps.
• Lobbying for appropriate checks and balances and transparency to curb corruption.
• Need for institutional strengthening and capacity building at the provincial level to – Ensure responsive service delivery with consistency and quality • All criticism apart, this is a unique window of opportunity to re-orient and
overhaul the public health system.