Post Devolution Challenges and Opportunities in

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LEAD UPDATE
Post Devolution Challenges
and Opportunities in Health
Governance in Pakistan
December, 2012
Inspiring leadership for a sustainable world
Stakeholder Dialogue
In order to learn more about the issues of
health governance particularly from
provincial representatives, LEAD Pakistan
organized a stakeholder dialogue on Post
Devolution Challenges and Opportunities in
Health Governance in Pakistan. This was
organized under the “Our World”- Women
Leadership in Reproductive Health (WLRHD)
Project.
Proceedings
Ali Tauqeer Sheikh, Chief Executive Officer,
LEAD Pakistan welcomed the participants. He
mentioned the assessment of poverty in the
multidimensional spectrum that has become
a growing concern of the developing world,
particularly Pakistan. “Poverty is often
defined by one-dimensional measures, such
as income. But one indicator alone cannot
capture the multiple aspects that constitute
poverty. Multidimensional poverty is made up
of several factors such as poor health, lack of
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Dr. Talib Lashari, Advisor (Health) – Planning
Commission of Pakistan was the chief guest of
the event. He said that the purpose of
devolution was a paradigm shift to bring the
grass root community closer to policy
planners and implementers.
“Devolution has not failed. It is an evolving
and learning process. We not only need to
focus on policy level , strategic issues but
need to address operational level issues as
well. At the strategic level, provinces need
guidance, vision and policy orientation; while
at the operational level province require
finances, reporting guidelines and trained
staff.”
Dr. Adnan, Director - Research & Development
Solutions presented LEAD's research on
Devolution in Health Sector (authored) by Dr.
Babar Tasneem Sheikh. He explained the pre
and post 18th amendment scenario and
mentioned the key strategies for health
system strengthening such as balancing cost
and sustainability, measuring and monitoring
health system's performance, tracking
expenditures through health systems and
allocating human resources to health
systems.
This was followed by a panel discussion
amongst the speakers and the participants.
The speakers were eminent policy,
governance and health experts as Mr. Azhar
Saeed Malik, Assistant Country Director &
Chief, Governance Unit – UNDP, Mr. Zafarullah
LEAD House, F7 Markaz, Islamabad, Pakistan.
Tel: +92 (51) 2651511, Fax: +92 (51) 2651512, Email: main@lead.org.pk
CSR
Governance
He urged the participants to discuss health
issues amidst the broader context of 18th
amendment, focusing on governance.
EDUCATION
The provinces enthusiastic and wary of the
transfer of powers, are now in the process of
developing respective health policies. It is
imperative than ever before to streamline
practices, institutions and policies in order to
lay the foundations of a more equitable and
more efficient health care system. The
commitment to achieve the health related
millennium development goals has also
become more challenging, forcing policy
makers and practioners to rethink solutions
and strategies.
education, inadequate living standard and
disempowerment. Inequity, inequality of
resources and poor governance has increased
vulnerability of the population causing
stresses on livelihood and demographic
patterns.”
HEALTH
It has been two years since the passage of
18th amendment that resulted in health
becoming a provincial subject, leaving
provinces more autonomous and more
powerful to decide about their health systems
roadmaps and health policies. The transition
witnessed several challenges of transfer of
roles and responsibilities, financing,
information sharing, institutional
coordination, human resource and service
delivery.
Environment
14th December 2012, Islamabad
LEAD UPDATE
Mr. Azhar Saeed Malik explained
the different forms of federalism centralized and decentralized,
some with clear division of power,
while others with overlapping
powers. He said that there was no
best model but the prime objective
was shared and self rule.
“Continuous dialogue and debate
is important especially amongst
intergovernmental offices. Rather
than fighting over resources and
p owe r, p rov i n ce s n e e d to
coordinate and cooperate with one
another.”
Mr. Zafarullah Khan agreed that
health should ideally be a
provincial subject. He requested
the donors and civil society to
support this process by investing in
the training of the civil service and
bureaucrats. He pointed out that
the flaws of our governance
s y s te m s u c h a s
lack of
accountability.
Dr. Mohsin Saeed explained the
impact on the health sector post
devolution. He said that federalism
had been devolved but in a
fragemented fashion.
The per capita expenditure on
health has increased from 0.23% in
2011 to 0.27% in 2012, but this
utilization is not reflected in the
infant mortality & maternal
mortality rates.
Commenting on the progress of
transition, he said that it has been
two years and the provinces still
did not have inter-provincial
coordination offices. “The vertical
programs such as Maternal,
Neonatal & Child Health (MNCH)
and LHW (Lady Health Worker)
Program have not received
adequate funding and there is no
institution to claim ownership,
provinces are devising health
policies in the absence of
benchmarks or standards , further
more there is no system to the
performance after implementation
of these policies. National and
cross border surveillance of disease
has been completely ignored and
there is utter confusion about post
Content by: Yumna Hasany, Muriyam Ali
MDGS. Good governance needs
proper vision but we are in state of
chaos and collapse.”
Dr. Ali Mir advised the need to
regulate private sector in the
provinces. He recommended
learning from evidence based
research and integrating health
with education models for better
results. He said that devolution
should further take place at the
district and union level to involve
the grass root community.
In order to get feedback on
devolution from the provinces,
government officials from health,
family planning (FP), lady health
worker program and related
departments/programs were
invited to analyze the situation.
Dr. Jafar Saleem, Advisor, National
Program on FP-Punjab said that
their departments needed
technical support to help frame the
health policy and to understand
financial framework and tools. He
mentioned the issue of adjusting
seats of LHWs as after devolution
this issue was capped and they
could not increase the positions for
LHWs. Procurement was also a
problem as the province did not
have technical experts to oversee
procurement of drugs.
Dr. Fahim from KPK shared the
experience that when the funds
were curtailed, KPK government
adopted an innovative model of
bridge financing. KPK was provided
with technical assistance in
drafting the health strategy by
DFID, proposing minimum health
service delivery package with an
integrated approach.
Dr. Hakim Ali Talpur, Deputy
Director – Health mentioned that
the donors and civil society should
play an active role in facilitation
inter-provincial coordination. It is
the responsiblity of the provinces
not the federal government to
promote coordination.
medical staff, lack of road network
in urban and rural areas, distant
location of health facilities and non
functioning of Basic Health Units.
He proposed devolution at the
district level for better
implementation and planning.
It is quite evident that in the new
arrangement, it is imperative to
interact with the provinces and
with the federal tier of
government. This is high time for
lobbying for instituting checks and
balances to ensure transparency
and to align our strategies for
better health service delivery.
T h e re co m m e n d at i o n s a n d
LIST OF PARTICIPANTS
Dr. Ahmed Isa
æ
Dr. Adnan Khan
æ
Mr. Ali Khizar
æ
Dr. Ali Mir
æ
Mr. Allah Rakha
æ
Mr. Aman Ullah Khan
æ
Dr. Anis Kazi
æ
Mr. Arsalan Tahir
æ
Mr. Azhar Malik
æ
Mr. Azhar Qureshi
æ
Dr. Fahim Khan
æ
Dr. Farhat Shaheen
æ
Ms. Fozia Chugtai
æ
Dr. Hakim Ali Talpur
æ
Dr. Hans Frey
æ
Dr. M. Jaffer Saleem
æ
Mr. Mansoor Qaiser
æ
Dr. Masood Qadir
æ
Dr. Mohsin Saeed Khan
æ
Dr. Muhammad Ashar
æ
Dr. Muhammad Qurban Ali
æ
Dr. Nadeem
æ
Dr. Naeem Mir
æ
Ms. Nosheen Akbar
æ
Dr. Saleema Gulzar
æ
Dr. Saman Yazdani Khan
æ
Dr. Samia Rizwan
æ
Mr. Sarfaraz Ahmed Abbasi
æ
Dr. Sarwat Mirza
æ
Dr. Taj Baloch
æ
Dr. Talib Lashari
æ
Dr. Tariq Majid
æ
Dr. Zafar Ikram
æ
Mr. Zafar ullah
æ
Mr. Zulfiqar Ahmad Cheema
æ
LEAD Staff
Dr. Taj Baloch, Member Board of
Governor – Strengthening
Participatory Organization (SPO) ,
Quetta explained the problems
being faced by Baluchistan
province. He mentioned problems
of non availability of competent
midwives and skilled birth
attendants, lack of security for
Ali Tauqeer Sheikh
æ
Hassan Rizvi
æ
Muriyam Ali
æ
Yumna Hasany
æ
Kapil Nadeem
æ
Omair Shabbir
æ
Naveed Ahmed
æ
Layout by: Abbas Mushtaq
December, 2012
Khan, Executive Director – Center of
Civic Education, Mohsin Saeed
Khan, Health Expert and Dr. Ali Mir,
Director Programs - Population
Council Pakistan.
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