Devolution, Governance & Health

Mohsin Saeed KhanPh.D, MPH, MBBS

Health Outcomes Numbers/annum

Newborn births 4,773,000

Newborn deaths 272,330

Infant deaths 377,440

Under-five deaths (includes newborn and infant deaths) 473,000

Number of Infants Born Low-Birth-Weight 906,870

Number of Maternal deaths 23,865

Source PDHS 2006-2007

Total Public Sector Expenditure in Billions

(Rupees)

2000-01

2001-02

2002-03

2003-04

2004-05

2005-06

2006-07

2007-08

2008-09

2009-10

2010-11

2011-12

0

10

20

30

40

50

60

70

80

90

Per Capita expenditure on Health in Pak Rupees

2000

-01

2001

-02

2002

-03

2003

-04

2004

-05

2005

-06

2006

-07

2007

-08

2008

-09

2009

-10

2010

-11

2011

-120.0

50.0100.0150.0200.0250.0300.0350.0400.0450.0500.0

Health Expenditure as % of GDP

2000-01

2001-02

2002-03

2003-04

2004-05

2005-06

2006-07

2007-08

2008-09

2009-10

2010-11

2011-12

00.10.20.30.40.50.60.70.8

0.72

0.59 0.58 0.57 0.570.51

0.57 0.57 0.56 0.54

0.230.27

Health system assessment Approach, USAID

Devolution Road Map Ministry of Health since 1970 2001 under the Local Government

Ordinance; Province to Districts July 1, 2011, 18th Constitutional

Amendment abolished seven federal ministries including Ministry of Health and transferred their roles to other federal ministries, divisions, and the provinces.

Devolution Road Map vacuum

as the devolved functions were not detailed out in any plan of action.

The functions that have been retained at the federal level were distributed to different ministries without setting up a coordination mechanism.

The Federal Ministry of Health

Till June 30, 2011, MoH responsible for (i) stewardship functions, including national

policy and planning; (ii) regulation and standardization including

pharmaceutical; (iii) medical Education; (iv) research and information; (v) central health establishment and

hospitals; and (vi) health care provision by managing

preventive and infectious disease control (eleven vertical programs), curative health care through tertiary care.

Fragmentation1. Planning and Development Division, 2. Economic Affairs Division, 3. Capital Authority Development Department, 4. Ministry of Inter Provincial Coordination, 5. Ministry of National Regulations and Services, 6. Cabinet Division, 7. Federal Bureau of Statistics, and 8. Provinces.

Provinces Health Strategies in Khyber Pakhtunkhwa,

Sindh and Punjab Vertical Program Management without

ownership

Programmatic Challenges

Issues of coverage (scope & scale) Poor access to health services Non-availability of adequate human

resource Population growth Low allocations for health Weak inter-sectoral interventions Duplication of efforts

Service & Performance Challenges

Financial instability No accountability for poor

performance Political interference Issues of equity Skilled HR

Confusion, Chaos & Collapse

coordination, international relationships, national and cross border surveillance, national information on health, international reporting coordination with and

among provinces, donor coordination, financial forecasting and resource

mobilization, and quality assurance

Actors Politicians – Out Focused Beurocrats – Input Focused Technocrat – Process oriented Research & Development

Specialists / Institutions – Driven by TORs

Donors – Guided by their own sets of priorities

So where do we want to go

Vision !!!!!!!!! Not on priority list

Burden of Disease (outcome) Not in the planning process

Fiscal Space Management systems and organizational

structures What is beyond MDGs

IK IK Syndrome

On “bottlenecks”Remember that in bottles, the neck is always on the top!

Insight from a blind woman

“There is nothing more pathetic than a man with eyesight but has no vision.”

Our best thinking got us here.

The problems that we face cannot be solved by the same level of thinking that created them.

Albert Einstein

Way Forward Embrace Error Redefine Roles Deliver Services Mobilize Resources Unpack Research

THE WISDOM OF TAOXVII RULERS

 Of the best rulers

The people only know that they exist,The next best they love and praise,

The next they fear;And the next they revile.

 When they do not command the people's faith,

Some will lose faith in them,And then they resort to oaths!

 But of the best when their task is accomplished, their work done,The people all remark, "We have done it ourselves."

 Source: The Wisdom of China and India by Lin Yuntang