Devloution in Health Sector by Dr. Babar Tasneem (4)
Transcript of 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