While health has attained a high-profile status on the development agenda in Pakistan, Dr Sania Nishtar of Heartfile – a non-governmental organisation working on health policy – is worried that with the recent devolution of institutions, health may be relegated to the back-burners and may not get the required space to breathe and flourish.

On the other hand, she also says that devolution is also an opportunity to garner better provincial ownership and oversight of this critical state mandate.

“Only time, and impact assessments will tell if reasonable resource allocation is made to health by each province, and if systemic impediments to health systems functioning are overcome,” she told Dawn.com on the sidelines of the IMF-WB annual meetings held from October 10-14 in Tokyo, where she was among the speakers at one of the seminars on health.

The state of global economic crises and measures to reduce poverty were at the heart of several forums and discussions at these annual meetings

According to the experts, access to medical treatment remains a crucial determinant in reducing poverty.

Nishtar, for her part, insisted that money spent on health should never be looked on as expenditure by governments but as an “investment”.

“It will have an economic payoff and a social payoff,” she said, adding: “The provinces may not have fully realised what’s on their plate yet. The issue of asymmetry in provincial capacity also needs attention. What is most critical is to address the current fragmentation of health at the national level and create an appropriate federal structure for health – one that resonates with the spirit of devolution.

With the elections just around the corner, in Pakistan, politicians would do well to heed the advice of World Health Organisation’s director general Margaret Chan, that those who do not talk of health “won’t get voted.”

Since the early 1990s, when the World Bank began talking about better investments in health and subsequently the Millennium Development Goals, Nishtar said, resource allocations towards health had been redefined drastically and gained a “political momentum, globally” never seen before. More recently, the WHO published its World Health Report in 2010 with Health Financing as a theme.

Since then, said Margaret Chan, 80 countries have already sought guidance to step up momentum towards universal health coverage (UHC).

This can be seen as the battle in the United States raged over access to healthcare and will continue till Barrack Obama is re-elected or loses to Mitt Romney. Yet a wind of change is sweeping across the world, in countries big and small, that are turning or even aspiring for a system that allows access to medical treatment to those who cannot afford it.

Many countries, even neighbouring India is heading towards UHC.

Unfortunately, that is not the case in Pakistan, at least not yet. One of the factors for that is low public demand. “The man on the street is overwhelmed by other more basic problems at the lower rungs of Maslow’s Hierarchy of needs, as a result of the law and order situation, the energy crisis, lack of economic opportunities, and relentless poverty.

“Although we are witnessing the beginnings of some attention to health by aspiring politicians, overall there is very little societal demand and in the absence of that there is no pressure on the state to improve performance in that area,” said Nishtar. “And to top that there is such a policy-implementation disconnect overall, that only a fraction of what is promised gets delivered,” she added.

“Many emerging market countries, which have embraced UC reform have the fiscal space to bring about reforms in the health sector. We, on the other hand are in the midst of big problems like internal strife, conflict, energy crises and economic downturn,” said Nishtar. These seem to have resulted in fire-fighting on the part of the state on a day-to day basis and distracting it from deeper policy reforms.

But to its credit, said Nishtar, Pakistan did not have a bad health system. “It has a good design, but one that does not work. The plumbing is there, the structure is there, but it’s bogged down with corruption,” she said referring to her book Choked Pipes. “We need to fix the system and incrementally put in more resources.”

According to official data, Pakistan spends 3.4 per cent of its GDP on health of which the public share is 0.9 per cent. “Ideally the public share of health financing should be predominant, which is not the case in Pakistan.” And of that spent by the government, a huge chunk is wasted – pilfered as well as abused in the form of absenteeism.

But Pakistan is not the only country facing this problem. Globally, 20–40 per cent of resources spent on health is wasted. Common causes of inefficiencies include demotivated health workers, duplication of services, and inappropriate or overuse of medicines and technologies.

With growing disquiet among young doctors seen recently on the streets of Lahore it is time perhaps to give health systems research (HSR) a thought.

Though relatively new, through this science of HSR, experts examine how people get access to medical treatment and health care providers and services. At the same time, it investigates how social factors, financing systems, organisational structures and processes, medical technology affect access to health care.

“A country’s human resource policy should be guided by need, policy priorities and resource realities. The doctors were promised certain incentives but the decision makers neither took resource realities into account nor the impact of devolution on possible ownership of prior decisions. When decisions of this nature are not based on a thorough review of evidence, problems of the kind we are encountering emerge,” Nishtar expressed.

The devolution plan should be seen as an opportunity to make the health care system truly responsive to the needs of people.

The author is a freelance journalist.