devloution in health sector by dr. babar tasneem (4)

8/19/2019 Devloution in Health Sector by Dr. Babar Tasneem (4)

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Devolution inHealth Sector

Challenges andOpportunitiesfor Evidence based Policies

byDr. Babar Tasneem Shaih


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• Before the present devolution

– Devolution in 2001 (LGO 2001)

– District Health System

• nder 1!th amendment

–

"#olition of the concurrent list – 1! ministries includin$ health andpopulation %elfare totallydevolved

Devolution in Paistan& the !'th (mendment


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Devolution in Paistan& the !'th (mendment

• &oncurrently'

– & "%ard of 2010*11

–

nprecedented share of finances andother resources transferred toprovinces

• Ho%ever'

–

nli+e education, health care not afundamental ri$ht

– -ro$ress in health indicators (.DGs /, ) very slo%

•

"ssociated health system constraints


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• ederal .inistry of Health in the

drivin$ seat• Operatin$ throu$h the concurrentle$islative list

• .ana$in$'

–

-rovincial health departments – 3leven vertical pro$rams

– Seven tertiary care centers

– ational Health .4S and other 4nfo

Systems

Pre)!'th (mendment Scenario


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Post !'th (mendment Scenario

• -rovinces more empo%ered to operate theirhealth systems

•

.inistry of Health a#olished• &&4 * the lin+ #et%een ederal -rovincial Governments

• ederal Gov can only le$islate on su#5ects

in second part of ederal Le$islativeLists

• Some functions of .oH dele$ated to ei$htinstitutional settin$s, %hich are'

–

.inistry of 4nter -rovincial&oordination (4-&)


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• -olicy formulation and health plannin$

devolved• Service delivery no% entirely %ith theprovinces

• ational H.4S replaced %ith DistrictHealth 4S

• Some pro$rams 7 8B, .alaria and "4DSetc9 7 retained'

– nder contractual a$reement

–

:ith the .inistry of 4-&• Dru 6e ulator "uthorit also retained

Post)!'th (mendment Scenario


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• "chievement of health related .DGs

– .oH a#olished

–

Leavin$ many areas unattended

• 4ssues of capacity in the provinces 7at least initially * in'

–Health plannin$ and re$ulation ofpolicies

– Strate$ic directions and leadership

– Health information $eneration

– Human resource development

Challenges and Constraints


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Challenges and Constraints

• :HO frame%or+ on #uildin$ #loc+s of health

system – Governance

– Service Delivery

– Health information

– inancin$ – Human 6esources

– .edical -roducts;8echnolo$ies


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Challenges and Constraints*overnance

• "#sence of ade


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Challenges and

Constraints Service Delivery

• inancial transfer sudden and %ithoutoptimal technical $uidance

• >ertical pro$rams facin$ issues of fiscalsupport

• &hallen$es of national service deliverypro$rams

– 4nter*provincial harmoni=ation

– &ontractual a$reements

– 6esource mo#ili=ation

– Donor preferences for one %indo%operations


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Challenges and ConstraintsHealth +nformation

• Lac+ of inte$rated disease surveillancesystem

• Lac+ of inter*provincial info sharin$mechanisms

• "#sence of collated info and irre$ularreportin$

• So there is limited utili=ation of infoand evidence for

– -lannin$ in national pro$rams

– "ssessment of health services

– Surveillance in case of disease


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Challenges and ConstraintsHuman ,esource

• Lac+ of trained staff resultin$ in

– nderutili=ation of primary health careservices

• neven deployment in ur#an and rural areas

• "#sorption of federal staff 7 additionalfinancial #urden

• &oncerns a#out service structures 7stri+es #y

– @oun$ doctors

– urses

– -aramedical staff


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Challenges and ConstraintsHealth -inancing

• -rovinces have up to /0A more funds, #ut

– :ea+ly planned process of reforms

– Slo% transfer of funds, and so

– >ertical health pro$rams facin$pro#lems

• o performance parameters due to lac+ ofcollated info

• -oor resource trac+in$

• &ompilation of provincial health accountsis a +ey challen$e

• :ith only 092A GD- spent on health,


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Challenges and Constraintsedical Products/Technologies

• &entrali=ed authority is re


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Provincial Health Sector Strategies

• "ll provinces (includin$ "C and GB)%or+in$ on them

• C-C has no% an approved strate$y

• Sindh and -un5a# to follo% suite

• Similarly for "C and GB

• Baluchistan, %ith its peculiar pro#lems,some%hat la$$in$ #ehind #ut %or+in$ on it

• Salient features of these provincialstrate$ies $iven in the paper

• Cey common features discussed in thefollo%in$ slides


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Provincial Health SectorStrategies

*overnance• 6evie% of ste%ardship function of DoH #yre*ali$nin$ its functions of policydevelopment, plannin$, reforms, monitorin$

and evaluation etc9• 3sta#lish a -olicy -lannin$ nit atprovincial level and staff it %ithcompetent professionals after competitive

selection9• Stren$then district health systemsstartin$ %ith most under*developeddistricts9

•6e$ulate the health sector, in particular


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Provincial Health Sector Strategies +nformation System

• 4nte$rate all national pro$rammesEinformation systems into the DH4S and

esta#lish functional lin+a$es #et%een alllevels of operation (facilities, district,provincial or federal mana$ement)9

•

6evisit the scope and content of the DH4Sso as to inte$rate data from LH:, .&H andD3:S etc9

• Lin+ tertiary care and the private sectorhealth facilities %ith district and


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Provincial Health Sector StrategiesHuman ,esources

• Streamline human resource production,retention and capacity to support priority

heath needs9

• Stren$then the personnel section at DoH toperform all human resource mana$ement

functions9

• Develop a continuin$ medical educationpro$ram for all medical, nursin$ andparamedical staff lin+ed to careerdevelopment9


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Provincial Health Sector StrategiesDrugs# Supplies 0 Technologies

• 4mprove availa#ility of


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Provincial Health Sector Strategies -inancing

• "llocate resources accordin$ to incidence andprevalence of diseases, cost effectiveness of apro$ramme; policy, and poverty levels9

• 4ntroduce safety nets to protect poor fromcatastrophic ependitures e9$9 social healthinsurance, community #ased health insurance,vouchers9

• 4mplement an inte$rated #ud$etary plannin$ process%here#y DoH has the mainstay in consultation %ithinance and -lannin$ Departments9

•

"li$n the donor fundin$ %ith DoH strate$y andpriority areas for investment9


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Provincial Health Sector Strategies Service delivery

• Develop, cost and implement an 3ssentialHealth Service -ac+a$e at -rimary Secondary levels9

• 6evitali=e the delivery of family plannin$services in the pu#lic sector healthfacilities9

• 4nstitutionali=e an operational referral

system from primary to secondary and fromsecondary to tertiary healthcare level9

• 6e*ali$n the .&H strate$ies andactivities in the li$ht of findin$s of

DHS9


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Health Systems 0 Policy+mplementation Post)Devolution

The Optimistic 1ie2

• -rovinces no% free to strate$i=e, plan andact %ithout federal dictation9

•"#le to provide vision, roadmap and frame%or+for steerin$ health affairs9

• Strate$ies #ein$ developed are more relevantand contet #ased on fresh, sound andsituation analyses9

• .ore intense and deeper consultation %ouldresult in $reater o%nership #y provincialsta+eholders9

• "ll strate$ies follo%in$ :HO standards and

#uildin$ #loc+s %ith uniform frame%or+ for#enchmar+in 9


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Health Systems 0 Policy+mplementation Post)Devolution& The

Do2n Side

• 8he %hole process suffered from a +nee 5er+reaction from the provincial $ovts 7 complaints of#ein$ unprepared, incapacitated and perhapsuna%are of the implications

• "n inte$rated and unified vision of health for all7

– :ho %ould ensure a common national vision andcohesive missionF

– :ould every province have a different vision,strate$y and $oalsF

– :ould there still #e a role of the ederal Govin this re$ardF

• 6e$ulation and standardi=ation no% also ideally

lie %ith the provinces9 Ho% %ould thisresponsi#ility carried out in the futureF


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3ey Strategies for Health SystemsStrengthening

• Buildin$ capacity for health system todeliver

• Balancin$ cost and sustaina#ility

• 4mprovin$ health $overnance

• -rotectin$ people from financial ris+s

• .easurin$ and monitorin$ health systemEsperformance

• -ayin$ for results to improve healthsystemEs performance

• 8rac+in$ ependitures throu$h healthsystems


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Opportunities and the 4ay -or2ard

• irst and foremost' educate ourselves, thepartners, the communities and all othersta+eholders9

•

4t is imperative to interact closely %ith theprovinces, and #arrin$ fe% areas, less %ith thefederal tier9

• -ra$matic approach to em#ar+ upon an actionoriented advocacy for plu$$in$ the $aps9

•

Lo##yin$ for appropriate chec+s and #alances andtransparency to cur# corruption9

• eed for institutional stren$thenin$ and capacity#uildin$ at the provincial level to

– 3nsure responsive service delivery %ith

consistency and


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Than 5ou

devloution in health sector by dr. babar tasneem (4)

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