DEVOLUTION PLAN AND HEALTH CARE IN PAKISTAN

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DEVOLUTION PLAN AND HEALTH CARE IN PAKISTAN
CHALLENGES AND CONSTRAINTS
Dr. Babar T. Shaikh The Aga Khan University,
Karachi, Pakistan.
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VISION

• Health is a basic human right and must be
  available and accessible in an affordable
  framework to all. To this end, an integrated
  approach to public health in the district will
  combine preventive, promotive and curative health
  at all levels. Reductions in demand of curative
  care, would be translated into improvements in
  its quality.
• Promoting good governance in health sector, by
  meaningful and consistent emphasis on prompt,
  equitable and professional services delivery,
  must become a cardinal principle of the
  department.

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Devolution, Decentralization, Debundling
It is the transfer of authority, or disposal of
power in public planning, management and decision
making from the national level to sub- national
levels or from a higher to lower levels of
government.
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Main Objective philosophical ideological
Providing the means for community participation
and local self-reliance and ensuring the
accountability of government officials to the
population.
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DEVOLUTION OF POWERS IN HEALTH DEPARTMENT
OBJECTIVES

• Empowerment of the people at the grass root
  level.
• To make the District the dominant level of
  decision making in health department.
• Improve the quantity and quality of health care
  delivery to the people close to their door steps.
• Integrated approach to public health, combining,
  preventive, promotive and curative health at all
  levels.

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RESPONSIBILITIES/ FUNCTIONS AT THE DISTRICT LEVEL

• Prevent and Control Communicable Diseases and
  Non Communicable Diseases.
• Food Sanitation.
• Maintain medical and health statistics under
  HMIS.
• Reproductive Health.
• Health and Nutrition Education.
• Environmental and Occupational Health.

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RESPONSIBILITIES/ FUNCTIONS AT THE PROVINCIAL
LEVEL

• Make Health Policy for the Province.
• Legislate on Provincial health Issues.
• Drugs control under the Drugs Control Act.
• Monitoring and Regulatory functions of
  Medical and Para Medical institutions.
• Health Research and related Health information
  gathering.

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RESOURCE/ASSETS DISTRIBUTION FOR THE DISTRICT

• Type-A or B DHQ Hospital hospitals.
• Type-C Tehsil HQ hospitals.
• Type-D Civil Hospitals
• RHCs.
• BHUs.
• Sub Health Centres.
• MCH centres.
• Dispensaries.
• Districts will be encouraged to establish their
  own Nursing,
• LHV and Paramedical Training Institutes in due
  course.

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PROGRESS SO FAR

• Posts in Directorate General of Health Services
  have been re-designated
• Budgets according to the new requirements.
• All DHOs and ADHOs have been briefed by the
  department twice on its approved Devolution plan.
• Briefing was held for both DHOs and DCs of all
  districts by Health Department
• All DHOs have been instructed to work as a team
  with the DCs at the district level
• All DHOs have been asked to develop lists of
  their assets for distribution

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ADMINISTRATIVE STRUCTURE
DISTRICT
District Coordination Officer
EDO Finance and Planning Health
Public Health
District Headquarters Hospitals
Basic Rural Health Centre
Mother Child Health
Population Welfare
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FUNCTIONS OF EXECUTIVE DISTRICT OFFICER

• Ensure that the business of the department and
  offices placed under his administrative control
  is carried out in accordance with the relevant
  laws and rules.
• Co-ordinate and supervise the activities of the
  relevant offices.
• Ensure efficient services delivery by
  functionaries under his control.

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DISTRICT HEALTH MANAGEMENT TEAM
What is the purpose of a DHMT ? P Develop a Team
approach P Share and Exchange Views P Reduce the
workload of the DHO P Optimize Utilization of the
Human Resources P Improve Cooperation and
Collaboration among stakeholders
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How is a DHMT Constituted ?
P     DHO P     Other District Managers P
    Public Sector Health Care Providers P    
Private Sector Health Care Providers P Community
or its elected leaders
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Role of DHMT

• Sharing of experiences and exchanging of views
  ideas.
• Taking responsibilities and improving technical
  efficiency by supporting, assisting.
• Improve cooperation and collaboration with the
  Government and private health related sectors.

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OUTCOMES

• Well-defined structures have been developed and
  resources allocated.
• Meaningful partnerships at provincial,
  district, tehsil and community level, through the
  establishment of DHMT,THMT and citizen boards.
• Detailed mapping of resources and services need
  to be developed.
• In planning and implementation of program a
  right based and integrated approach needs to be
  developed.
• Meaningful action and capacity building would
  be required at all levels.

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HEALTH EXPENDITURE SITUATION AT PRESENT

• Almost 100 is out-of pocket
• Includes formal and informal private sector
• Questionable quality of care
• Considerable expenditures on unnecessary and
  inappropriate (sometimes unsafe) care
• Inequity in financing of care
• No regulation or standards on fee charged
• Reliable information not available

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ADVANTAGES OF DEVOLVED SYSTEM IN HEALTH CARE

• Administrative and financial powers to district
  authorities / local bodies representative.
• Involvement in devising the programs relevant to
  the local needs and priorities.
• Strategies and plans acceptable for the community
  and matching to their socio cultural and socio
  economic background.

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• User willingness to pay for PHC in the public
  sector services, if they receive improved care.
• The districts can recover substantial costs and
  can retain the incomes.
• Creating sense of ownership.
• Strengthening of FLCF, answering many primary
  health problems like high IMR, high MMR and
  morbidity and male involvement.

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CRITERIA FOR ALLOCATING DISTRICT BUDGETS

• Population Size
• Socio-economic Development
• Health Infrastructure
• Health Needs / Problems (BOD Estimation)
• Performance Evaluation based on
• predetermined indicators
• Combination of Above

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CHALLENGES AND CONSTRAINTS

• Political willingness of provincial and district
  governments to work in the new system.
• Defining their administrative roles with limits
  and jurisdiction.
• Distribution of financial powers between
  Provincial and District representatives.
  (dependency of districts on provinces for how
  long?)

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• Financial and administrative capacity of the
  district government.
• Resentment against the status quo at the
  provincial level and fear of loosing authority.
• Lack of trust and losing the profit.
• Status of Public Service Commission, Medical
  colleges and Tertiary hospitals.

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THE INTERNATIONAL DEVELOPMENT TARGETS
1. A reduction by one half in the proportion of
people living in extreme poverty by 2015 2.
Demonstrated progress towards gender equality
and the empowerment of women by elimination
gender disparity in primary and secondary
education by 2005 3. A reduction by two-thirds
in the mortality rates for infants and children
under age 5 and reduction by three-fourths in
maternal mortality - all by 2015