Transcript Attaining MDGs 4

Systemic Issues and Strategic Responses
Eighteenth Amendment:
Rationale
A milestone in constitutional history; Towards strengthening
parliamentary democracy and greater provincial autonomy
“WHEREAS it is expedient further to amend the
Constitution of the Islamic Republic of Pakistan for the purposes
hereinafter appearing;
AND WHEREAS the people of Pakistan have relentlessly struggled
for democracy and for attaining the ideals of a Federal, Islamic,
democratic, parliamentary and modern progressive welfare
State, wherein the rights of the citizens are secured and the
Provinces have equitable share in the Federation;” (Preamble to
the Amendment Bill)
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Health Federalism--- International
practices
 Public health system i.e preventive, promotive,
bulk of curative care; enforcement of standards are
local/provincial/state subjects
 Standards, compliance, surveillance & advance
research & development require federal support &
coordination
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What Effectively Changed?
 “Is Health now exclusively a provincial
subject”?.
Not
completely true
 Regulations of profession now exclusively a federal subject
 (E 43 shifted from CLL to Pt. II of FLL)
 Drug standardization & pricing now exclusively a provincial
function
 (E 20 taken out of CLL)
 Financing & management of vertical programs transferred to
provinces
 (shift in governance paradigm)
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----- Contd.
 Disease surveillance now exclusively a provincial
subject
 (E 22 taken out of CLL), except for surveillance at
international borders (E 19)
 Specialized Research and Development a federal
subject
 E 16 of Part I of FLL
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Health Related Federal Functions:
Post 18th Amendment
 “National
planning and economic coordination,
including planning and coordination of scientific and
technological research” (Entry 7 in Part II of FLL)
 “International treaties, conventions and agreements
and international arbitration” (Entry 32 in Part I of FLL
substituted)
 “Legal, medical and other professions” (Entry 11 in Part
II of FLL. Formerly Entry 43 of CLL)
 “ Drugs and Medicines” originally devolved yet
handed back to Federal level under Article 144 (DRAP
Ord.)
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Health Related Federal Functions:
Post 18th Amendment
 “Enquiries and statistics for the purpose of any of the
matters” in the Part I (Entry 57) and Part II of FLL
(Entry 17)
 “Import and export across custom frontiers, as defined
by the Federal Government, interprovincial trade and
commerce with foreign countries, standard and quality
of goods to be produced outside Pakistan” (Entry 27 of
Part I of FLL)
 National Health Insurance, where there is a void at
provincial level (Entry 29 of Part I of FLL)
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Opportunities
 Provinces have greater ownership of health sector
management
 More autonomy and flexibility in devising policies and
implementation strategies
 Health Sector Strategies developed by three provinces
 Greater possibility of integration of health services
 Focus of International partners shifts to provinces
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Challenges
 Constitutional/ Legal
 Managerial and Transitional
 Capacity Issues
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Challenges ---- Constitutional/Legal
 Provision of health care requires complex interaction
between federal, provincial & local levels
 Abolition of CLL
 Note
of Reiteration by Mr. S.M Zafar, Member
Parliamentary Committee on Constitutional Reforms
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Challenges ---- Constitutional/Legal
“ Almost all the known and functional federations in
existence since last 200 years have successfully and
satisfactorily operated within the framework of three lists ------------ Omitting Concurrent List altogether shall confront
the county with innumerable problems including the
overburdening of CCI ------Though certain subjects can be
and should be transferred from the concurrent to the
provincial list, complete omission of the Concurrent List will
be inappropriate, impolitical, risky and violative of one of the
basic structures on which 1973 Constitution was founded.”
(Note of Reiteration By Mr. S.M Zafar. Annex D-1 of the
Parliamentary Committee on Constitutional Reforms’ Report)
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Challenges ------- Transition
Management and Coordination
 Ministry of Health Abolished
 Dispersion of health related subjects to a
number of Ministries and agencies at the
federal level
 Problems of coordination among Federal
Ministries and between provinces and
Federal government
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*Health and the 18th Amendment: Retaining national functions in devolution.
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Challenges ------- Transition
Management and Coordination
 National Health Policy formulation ???
 “Overarching norms or a set of values and principles at
the national level”
 “Health systems‐related functions with a truly national
character, e.g., health information, disease security,
compliance with international regulations, and trade in
health”
 Management of transition runs into serious problems
 Issues of coordination with international partners
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* Dr. Sania Nishter in Health and 18th Amendment
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Challenges ------- Transition
Management and Coordination
 Serious issues with Interprovincial disease
surveillance
 Data collection and consolidation for key
health indicators at national level
 Possible under E 7 and 17 of Part II of FLL
but lack of ownership at central level
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Conclusion
 18th Amendment offers opportunities as well as poses
challenges
 Challenges arise partly out of the new constitutional
scheme
 Partly because of the way transition was handled
 Capacity constraints at bureaucratic and technocratic
level
 Political consensus between central and provincial
governments
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Recommendations
In the Short Run
 Establish a loose coordination mechanism at
Federal level for integrated management of health
sector issues
 Building political consensus is a pre-requisite for
this
 Provinces’ concerns need to be addressed
 Focal point for interprovincial and international
coordination on behalf of the country
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Medium to Long Run
 Developing systems and capacities for interprovincial
diseases surveillance (E 7 of Part II of FLL)
 Coordination mechanisms for attaining major health
objectives and collection of data for the purpose (E 7 &
17 of Part II of FLL)
 Interprovincial
coordination
for
streamlining
international support and meeting international
commitments (e.g CCM) (E 32 of Part I of FLL)
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Medium to Long Run
 Restructuring of Provincial Health Departments
 Archaic structures and serious issues of capacity and
resources.
 From control and administrative mode to stewardship, policy
formulation, financing and oversight role
 To be realigned on functional basis ----- HRM,
Procurement & Logistics, Financing and Budgeting,
Reforms and Development
 Strengthening Directorate General Health Services by
institutional restructuring and attracting and retaining
good quality HR ----- (Don’t be penny wise, pound foolish)
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Maternal Mortality
Maternal Mortality
 MMR 227 per 100,000
 5,400 women die for maternal causes in
Punjab
 49% pregnant women anemic
 Iron supplement intake during pregnancy is
only 24%
 12 % pregnant women found to be Vitamin
A deficient
Framework
 Addressing Three Delays
 By developing strong Linkage between community
based workers and health facilities
 Maternal emergency ambulance services linking
community to health facilities
 Strengthening Basic and C-EmONC services at
primary and secondary levels
 Rotation visits of specialists from tertiary to secondary
level facilities
Framework
 Aggressive strategies for filling HR gap in specialties
such as gynecology, anesthesia etc
 Demand side financing for the targeted population
 Involve private sector in health voucher and insurance
schemes
MICS Results (2011)
Indicator
MICS 200304
MICS 200708
MICS 2011
MDG Target
U-5
Mortality
112
111
104
IMR (Revised
86
86
82
40 per 1,000 LB
TFR
4.7
4.3
3.6
2.1 %
Skilled Birth
Attendance
33
43
59
< 90%
ANC
coverage
(one time)
44
53
74 (40 % 4
antenatal visits)
< 90%
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Methodology)
Progress.
Yes, but too slow
Systemic Issues
 Financing is adequate?
 No. Only 0.7 % of GDP
 PHE around US $ 8.5 per capita (Size of envelope?)
 Is financing equitable ?
 No. OOPE around 70% (Social Safety Nets?)
 Health Human Resource
 Availability? low, irregular, uncertain
 Mal-distribution issue
 Poor motivation levels
Systemic Issues
 Service Delivery Management
 Fragmented, vertical in approach
 Poor M&E systems
 Capacity issues
 Lack of adequate performance based incentives
 Information System
 Existent but not very efficient
 Fragmented
Systemic Issues
 Medical Products & Technologies
 Procurement systems seriously deficient
 Lack of effective regulatory oversight
 Absence of effective pharmacovigilance system
 Absence of health technology assessment tools
Systemic Approach
 Defining roles
 Government ----- stewardship, financing, regulatory
oversight
 Health professionals ----- service provision, technical
inputs to policy formulation
 Contractual relationship
 Building Systemic Capacity
 HRM & Development
 Procurement
 Regulatory oversight
 Financial management
Systemic Approach
 From inputs and process based approach to output
and outcome oriented approach
 Measure performance against clearly laid down
benchmarks
 Link performance with reward and penalties
 Decentralize at district level----- with adequate
oversight, support and accountability from provincial
levels
Systemic Approach
 Develop health specific social safety nets
 Health voucher schemes
 Social health insurance
 Design, pilot, scale up
Recommendations
 Is all of this doable?
 Why not attained so far?
 Systemic capacity issues
 Lack of focus and will
 Quick dividends are more sought after
 System building is a painstakingly long process.
Who will reap the benefits?
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What is the Way Out?
 Keep on trying
 Develop reform ideas and document them
 Translate them into strategy documents
 Build coalition of civil servants, health professionals,
politicians, media persons etc
 Advocacy, advocacy, advocacy
 Systemic changes don’t come in weeks and months.
May take years, even decades
 But don’t hesitate from making good beginnings
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‘Journey of a thousand miles
begins with a small step’
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Thank You