It was in a meeting abroad that I was first posed this question by a fellow Pakistani: ‘Don’t you think the health sector has suffered because of decentralisation? Don’t you think we’d be better off if health became a federal subject again? What’s the point of decentralisation if people aren’t benefitting?’

I wondered at the argument back then. Wrap up decentralisation? Why not address the lacunae in the system instead?

Recent measures have fuelled the notion that there is more to the rolling back of decentralisation than meets the eye. And perhaps, this juncture, in time, provides us with the opportunity to critically assess whether decentralisation has helped health governance or impeded it, and if so, how.

Decentralisation is widely practiced across low- and middle-income countries and Pakistan is no exception to the rule. But typically the dialogue on decentralisation gets narrowly limited to health performance targets. What falls through the slats is that decentralisation is a radical political change with redistribution of responsibilities and resources — assessment of decentralisation is incomplete unless the process and politics of decentralisation are also examined. Which is why decentralisation results are unpredictable, depending on the context in which it is implemented.

Pakistan’s current provincial decentralisation came into effect with the passing of the 18th Amendment to the Constitution, on April 19, 2010. This was not a technical aseptic measure — with unanimous consensus of all political parliamentary parties, 21 sectors were devolved to the four provinces.

One of these was health — rather health was sent back to the provinces being constitutionally always a provincial subject but with blurring of federal-provincial authority lines over the years. The provinces were to now legislate, steer and manage the health sector as per their budgetary constraints.

Have they performed and can they deliver?

Preliminary results from the Demographic health Survey for Sustainable Development Goals (SDGs) health targets show that there has been reduction in deaths of infants and under-five-years children, coverage of pregnancy care visits by health providers has increased, skilled birth attendance has also gone up in all provinces, basic vaccinations coverage has increased in at least three provinces. But family planning targets have seen little improvement.

In the new debate surrounding the 18th Amendment, critics argue that benefits are not being transferred on to citizens. But such blanket assertions don’t take into account the politics and processes involved …

Let’s analyse health progress against some of the core objectives for which devolution was passed: (i) did devolution result in health getting a more equitable share of government funding? (ii) did provincial policy role lead to improvements in the health planning process? (iii) did provinces implement more locally responsive solutions?

But we must not confuse mix this with the prior attempts at decentralisation — these were attempted as part of local government reforms in 1959, 1979 and 2001. The case of weak local government absorptive capacity, low revenue generation and potential for domination by chieftains in a tribalistic society, has already been well documented by development economists. At least in health, the last district decentralisation led to little increase in the MDG targets, in certain places even a reversal.

WHAT IS HEALTH DECENTRALISATION?

Health has constitutionally been the provincial government’s responsibility. However, the presence of a concurrent legislative list allowed the fluid sharing of powers between the federal and provincial government. This complicated matters.

In practice, the federal ministry took a lead in health planning, service delivery programming, monitoring, aid coordination, licencing and regulations of drugs and human resource.

Over time, it also expanded into funding and management of the larger health hospitals. Provincial governments, while being major co-financiers of health, provided a passive role confined to administration of hospitals, clinics and programmes. The 2010 devolution provided an exclusive shorter list of federal powers and a longer list of exclusive provincial powers. The functions of health planning, legislation, service regulation, financing service delivery, human resource production, and service delivery programming were devolved to the provinces.

It must be noted that devolution would have been a hollow exercise had it not been made possible by a historical change in the federal-provincial resource distribution formula of 2009, with a majority share (56-58 percent) going to the provinces. The 2009 NFC Award provides an equity-based formula for distribution of resources to the less-populated provinces by factoring in development needs and security challenges of the smaller provinces.

The process of transitioning of power from federal to provincial government was abrupt. During the 14 months between devolution being promulgated into law (April, 2010) to abolishment of the Ministry of Health (MoH) in June, 2011, there was scant discussion and planning undertaken by the federal health ministry with the provinces. With impending abolishment of the health ministry, staff scuttled to find new jobs, yet others thought it would be reversed, leaving scant time for preparing provincial officials. Hence provinces were almost overnight confronted with additional responsibilities with resourcing and planning yet to be worked out.

“The provincial governments were not prepared for the post-devolution scenario,” explains one official in a provincial health department. “Only one workshop was conducted whereby the future of NIH Islamabad was discussed in light of devolution, but federally-managed tertiary institutes were not thrashed out. As a result, we had a fiasco at the Jinnah Postgraduate Medical Centre and the matter went into litigation.”

Dispersion of federal powers into the remaining federal institutions resulted in major issues with drugs licensing, vaccine procurements and regulation of medical and nursing professions, in the early days of devolution — these were solved through a healthy consensus moved through the Inter-Provincial Ministry. Health functions were later hurriedly reassembled into a separate federal ministry in 2013 during the tenure of a caretaker government through a direct executive order. Renamed as the Ministry of National Health Services Coordination and Regulation (MoNHSRC), it has struggled to recover legitimacy as its existence is often times contested both by the provinces as well as the federal entities to which its functions had originally been passed on. Politically, also, it has been sidelined as a low-resourced ministry with less clout.

HAS THERE BEEN MORE SPENDING ON HEALTH?

Provinces reacted to devolution through a visible increase in government spending on health, so far. Increased budget allocation for health is seen in all provinces ranging from 50 percent to threefold, more so especially in Balochistan and Sindh. There is also a visible rise in per capita health allocations by provincial governments. At the same time, the provinces have struggled with insufficient and delayed money transfers from the federal pledges committed pre-devolution. Insufficient federal fiscal transfers precipitated doctor strikes at leading tertiary hospitals, protests by community health workers, and out of supplies of vertical programmes in early years of devolution, until the gap was partially adjusted by provinces through their own resources or international donor support.

The provincial governments were not prepared for the post-devolution scenario,” explains one official in a provincial health department. “Only one workshop was conducted whereby the future of NIH Islamabad was discussed in light of devolution, but federally-managed tertiary institutes were not thrashed out. As a result, we had a fiasco at the Jinnah Postgraduate Medical Centre and the matter went into litigation.”

The increased allocations have been well utilised, with a budget execution rate of over 75 percent across the provinces. But questions remain about how well have these resources been allocated? Salaries continue to consume the major portion of the provincial health budgets and the share has even risen in some provinces, with less investment in supplies and quality of care. Budgetary increases are mainly used for recruitment of doctors and specialists rather than less costly frontline health workers more suitable for Pakistan’s underserved rural areas. More hospital infrastructure schemes remain popular, but, with an already over-extended public sector network, the need of more hospital schemes versus improvement of existing district hospitals is debatable.

HAS PLANNING IMPROVED?

Health planning in Pakistan was confined to planning for specific government projects and policies were few — only four health polices formulated in Pakistan’s 64-year history prior to devolution — aspirational and not translated into operational planning. Sector-wide health planning was kickstarted as an outcome of devolution, to fulfil the vacuum of response, and can be listed amongst the tangible achievables.

“Devolution was thrown to the provinces with a single stroke of a pen,” says a senior provincial health department official. “The provinces neither had the capacity nor were they administratively ready to take this up. That is when we decided to develop a provincial health sector strategy.”

Over the first two years of devolution, the provinces came up with province-specific health sector strategies laying out a 10-year strategic direction across public and private health sectors, assisted by donor agencies.

In most of the provinces, the planning process moved downstream to the development of district health plans. Roadmaps are in place in Punjab and Khyber Pakhtunkhwa to improve public service delivery using defined targets, regular stock-takes and investment in digitalised monitoring.

Certain level of re-structuring of provincial health departments has also taken place to steer health stewardship but more in the northern provinces. A couple of provinces have established policy or reforms units, and Punjab has further restructured the health ministry to create a new department for primary and secondary care to ringfence administrative attention and resourcing for primary care. Are health strategies, plans and restructured units a cosmetic measure only?

So far, they remain unevenly implemented, only partially adjusted within health budgets, and are frequently deviated from in favour of ad hoc schemes that have electoral visibility. Yet they are guiding documents to be refreshed, expanded, and aligned with budgetary planning especially with the start of the new governments.

WERE LOCALLY RESPONSIVE SOLUTIONS PUT IN PLACE?

A plethora of governance initiatives have been put in place to improve health care delivery, more in some provinces than others. Much required healthcare legislations have been put in place across all four provinces. These are directed towards important health reform areas of public private partnerships, health services regulation and autonomy of teaching hospitals. Surprisingly such legislative activity was not seen in the decades before devolution.

Considerable expense has gone across all provinces into refurbishing district hospitals. Licencing of private health providers to reduce quackery is in place now in three provinces. In Punjab, market surveillance of pharmacies is underway with e-tagging of drug retail outlets, quality testing of drugs, and a strengthened workforce of drug inspectors. Sindh is purchasing private sector expertise for running of ambulance services and professionalised management of government services. Khyber Pakhtunkhwa has initiated its own health insurance scheme for accessible medical care to the poor. And digitalised technology is in place across Baluchistan to all three provinces for improving childhood immunisation.

Provinces have amorphously transplanted initiatives from each other and there is a healthy competition to forge ahead in performance.

“Provincial planners and implementers like to learn from each other and even compete in performing in certain areas such as regulation and public private partnerships,” says an independent health expert.

The task now is to consolidate these effectively into practice. This requires infusing softer skills and technology for regulation, hospital management, private market management, amongst others in provincial ministries and common standard setting by the federal ministry. It also requires digging out of lessons learnt on what has worked well before rushing into more initiatives.

HOW CAN WE DELIVER BETTER?

Strong political support for devolution and visible ownership of health in all four provinces has increased resourcing of health from the government budget, pushed out with provincial planning, roadmaps and legislations as well as supported governance initiatives for improved delivery. Let’s look at reasons behind the gaps.

It must be understood that the provinces had a disadvantaged start in terms of technical capability as the past context of federally-dominated leadership, fiscal and administrative power stunted the maturity of provincial health departments. And the abrupt transfer of power with dragging of feet by the federal health ministry created further issues and unresolved financial gaps that continue.

Federal dialogue with provinces on health has remained ad hoc post-devolution, precipitated by crisis, such as polio outbreaks or new vertical initiatives, rather than coordinate on a common national direction. And sadly, technical assistance provision to the federal health ministry to meet its new role of coordination and regulation has been over-looked by international donors, so it is poorly equipped to meet its new role.

“We have asked time and again for the federal ministry to bring the provinces on a single platform to resolve common issues, we also would like to see what is happening in other provinces, but so far nothing has moved,” claims a provincial planning and development official.

In the provinces, despite an appetite for health reforms, the civil bureaucracy has never been groomed in stewardship of social sectors, which is an altogether different set of skills from routine public administration. Posting an honest secretary is just not enough, but needs health leadership training as well as the backup of provincial health departments and districts with professional human resourcing, technology and financial management systems to deliver to speed. And provincial health secretaries are changed frequently interrupting the momentum of progress, whereas health DGs are increasingly less empowered.

“Frequent transfer and postings at senior management level, especially of the health secretary, results in coordination gaps to address health issues and also a lack of interest at all levels,” complains a development partner.

Another issue worth pointing out is that the loosening of federal verticality made the provinces vulnerable to local political pressure for visible health infrastructure projects of less health value, recruits from local constituencies and, at times, hindrances in holding health staff accountable. Provinces where health departments had strong executive backing were better able to withstand political pressures, but not others. Such pressures are likely to be amplified in shifting down of powers to the district level in a country dominated by power and patronage issues.

WRAPPING UP

In decentralised Pakistan, health had increased government allocations, sector-wide planning and a historical proliferation in governance innovations. Implementation progress remains uneven, with some initiatives widely rolled out and others only partially implemented or even aborted.

This needs sorting rather than an argument of failure.

Feeble national health coordination by the federal level and insufficient investment by provincial governments in health stewardship capacity and re-structuring are constraints. Vulnerability to local political interference is another bottleneck requiring firewalling. Health decentralisation will require continued federal-province engagement on sorting unresolved boundaries, rather than drawing up adversarial positions. A common national direction is needed for joined up delivery but with authority and resources for contextually responsive provincial solutions in a country of more than 200 million.

The writer is an associate professor of health policy and systems at the Aga Khan University.

This essay has been derived from the PRIMASYS Pakistan case study and an upcoming academic publication in British Medical Journal-Global Health

Published in Dawn, EOS, February 3rd, 2019