Devolution and health

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  • 1. DEVOLUTION PLAN AND HEALTH CARE IN PAKISTAN CHALLENGES AND CONSTRAINTS Dr. Nayyar Raza Kazmi Courtesy Dr Babar T. Shiekh, Aga Khan University

2. 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.

3. 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. 4. Main Objective:philosophical & ideological Providing the means for community participation and local self-reliance and ensuring the accountability of government officials to the population. 5. DEVOLUTION OF POWERS IN HEALTH DEPARTMENT OBJECTIVES

  • Empowerment of the people at the grassroot 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, promotiveand curative health at all levels.

6. RESPONSIBILITIES/ FUNCTIONS AT THE DISTRICT LEVEL

  • Preventand ControlCommunicable Diseases and Non Communicable Diseases.
  • Food Sanitation.
  • Maintain medical and health statisticsunderHMIS.
  • Reproductive Health.
  • Health and Nutrition Education.
  • Environmental and Occupational Health.

7. 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 ofMedical and ParaMedical institutions.
  • Health Research and related Health information gathering.

8. 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.

9. PROGRESS SO FAR

  • Posts in Directorate General of Health Serviceshave been re-designated
  • Budgets according to the new requirements.
  • All EDOs(H) and ADHOs have been briefed by the department twice on its approved Devolution plan.
  • Briefing was held for bothEDOs(H) and DCOs of all districts by Health Department
  • AllEDOs(H) have been instructed to work as a teamwith the DCOs at the district level
  • AllEDOs(H) have been asked to develop lists of their assets for distribution

10. Public Health District Headquarters Hospitals Basic Rural Health Centre Mother & Child Health Population Welfare EDO: Health District Coordination Officer DISTRICT ADMINISTRATIVE STRUCTURE: 11. FUNCTIONS OFEXECUTIVE DISTRICT OFFICER

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

12. DISTRICT HEALTH MANAGEMENT TEAM What is the purpose of a DHMT ? Develop a Team approach Share and Exchange Views Reduce the workload of the DHO Optimize Utilization of the Human Resources Improve Cooperation and Collaboration amongstakeholders 13. How is a DHMT Constituted ? E DO(H) Other District Managers Public Sector Health Care Providers Private Sector Health Care Providers Community or its elected leaders 14. 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.

15. OUTCOMES

  • Well-defined structures have been developed and resourcesallocated.
  • 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 bedeveloped.
  • In planning and implementation of program a right based andintegrated approach needs to be developed.
  • Meaningful action and capacity building would be required atall levels.

16. 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

17. ADVANTAGES OF DEVOLVED SYSTEMIN 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,ifthey 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.

19. 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

20. 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?)

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.

22. 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 genderequality and the empowerment of women by elimination gender disparity in primary and secondary education 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