Title: DEVOLUTION PLAN AND HEALTH CARE IN PAKISTAN
1DEVOLUTION PLAN AND HEALTH CARE IN PAKISTAN
CHALLENGES AND CONSTRAINTS
Dr. Babar T. Shaikh The Aga Khan University,
Karachi, Pakistan.
2VISION
- 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.
3Devolution, 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.
4Main Objective philosophical ideological
Providing the means for community participation
and local self-reliance and ensuring the
accountability of government officials to the
population.
5DEVOLUTION 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.
6RESPONSIBILITIES/ 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.
-
7RESPONSIBILITIES/ 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. -
8RESOURCE/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.
9PROGRESS 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
10ADMINISTRATIVE STRUCTURE
DISTRICT
District Coordination Officer
EDO Finance and Planning Health
Public Health
District Headquarters Hospitals
Basic Rural Health Centre
Mother Child Health
Population Welfare
11FUNCTIONS 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.
12DISTRICT 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
13How 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
14Role 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.
15OUTCOMES
- 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.
16HEALTH 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
17ADVANTAGES 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.
18- 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.
19CRITERIA 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
20CHALLENGES 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?)
21- 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.
22THE 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