I RECENTLY came across a letter from the Prime Minister’s Office, bearing the title “Committee on Rightsizing the Fede­ral Govern­ment”. As I read, I discovered that in its third meeting, the committee had decided to take aim at five federal ministries/divisions, one of which is National Hea­lth Services, Reg­u­l­ation and Coor­dina­tion (NHSRC). It triggered in me a sense of déjà vu; here is why.

The Federal Min­istry of Health (MoH) was abolished in 2011 as a result of the 18th Constitutional Amendment

In the enthusiasm of devolution, it was thought that the federal government had almost no role in the healthcare sector and it, along with 17 other subjects, was devolved to the provinces.

After this, most federal institutions were moved to the provinces, while some were retained at the federal level and distributed among nine federal ministries and divisions, causing chaotic fragmentation of the health sector at the national level.

For example, the national immunisation program (EPI) went to the Ministry for Inter-Provincial Coordi­nation (IPC), the polio programme went to the PM Office; the National Institute of Population Studies went to the Ministry of Planning and the National Institute of Health and the Pakistan Institute of Medical Sciences (Pims) were assigned to the Cabinet Division.

It was quite a mess, and continued until 2013.

In 2013, Dr Sania Nishtar joined the caretaker government of PM Mir Hazar Khan Khoso. As a physician, her natural inclination was towards health, but since there was no ministry for that, she was made a focal person for health, along with three other ministerial portfolios, and she set herself the task of sorting out the piecemeal national health sector.

Her frame of reference was the Federal Legislative List, Part I of which outlines mandates that lie purely in the federal purview. For subjects covered under Part II of the list, the Council of Common Interests is the competent authority. These are subjects of the federation and not the federal government.

To her credit, Dr Nishtar single-handedly consolidated the administrative responsibilities of 19 departments, mandates and/or functions into a single federal-level entity and renamed it the NHSRC. She also used this opportunity to bring together health and population, a four-decade old unique and distorting anomaly that existed in Pakistan.

On May 3, 2013, amendments were made to the Rules of Business and subjects and staff was moved to NHSRC through a transition committee, which she chaired. Finally, she wrote a mandate and remit paper for the NHSRC with a view to outline the constitutional legitimacy and rationale for its creation.

In undertaking this work, 20 countries with federal forms of governments across the world were analysed and the organisation of their health sectors at federal level were studied.

So, we abolished the federal health ministry in 2011, worked without it for almost three years, realised that this doesn’t work and recreated a federal division, currently working as the NHSRC.

When I took over in April 2019, I asked for a headcount and found that we had 345 personnel in the ministry (excluding, of course, associated federal organisations). A closer look revealed that there were only 11 staff members who had any educational background in health sciences. The rest of them, from the federal secretary down to the level of a janitor, were either administrative or support staff. The chief technical officer in the ministry, the director general (DG) health, was lower in grade than joint secretaries, and was treated accordingly by many non-technical bureaucrats.

At the time, I brought this to the attention of the prime minister and he was flabbergasted. With the support of Dr Ishrat Hussain (who was the PM’s adviser on restructuring of the federal government) I developed a new organogram of the ministry and got it approved from the cabinet. But it could not be implemented because of resistance from the bureaucracy.

Having lived through these problems, I understand clearly that in its current form, the NHSRC is a highly inefficient and opaque organisation. Having said this, I must also strongly emphasise that a slim and smart federal structure for health is very much the need of the hour.

In rightsizing the NHSRC, attention to transparency in governance, accountability, plugging leakages and pilferages from the system, ensuring attention to merit, building safeguards against conflict of interest, upholding the rule of law, and evidence-based decisions need to be ensured.

There is a definite federal role in the delivery of healthcare services that cannot be filled without a purpose-built federal health organization and a dedicated, authoritative leadership.

The federal functions include health information and research; regulation; information communication technology in health; financing; human resources; international health agreements; and health and population interface.

For functions that are the remit of the federation, the federal health organisation has to work closely with the IPC ministry, since it serves as the secretariat of the CCI.

A national vision for health should be followed by the federating units. There is a strong need for federal-provincial and inter-provincial policy coordination. As witnessed during the Covid-19 pandemic, emergencies require such structures to be in place.

Global health engagement, too, has to be carried out at the national level. In May this year, there was no high-level official representation from Pakistan at the World Health Assembly in Geneva, where the health ministers of 194 countries meet annually. The fifth largest country in the world, teeming with public health issues — including being among the last two countries that has failed to eradicate polio — and there was nobody from Pakistan with whom the rest of the world could engage.

We move in extremes. We abolished the ministry then reassembled it. Now, once again, we seem to be going after it. “Rightsizing” is the right term. NHSRC should be drastically trimmed, consolidated federal functions should be retained and a unified leadership at the level of a federal minister should be restored.

We should be thankful to Dr Nishtar for leaving behind an institutional memory of resurrecting the federal health organisation and we should learn from it, rather than repeating old mistakes and losing time, money and effort in the process, not to mention the dire state of the health of the nation.

The writer is a former health minister and currently a professor of health systems & population health at Shifa Tameer-i-Millat University.

Published in Dawn, July 15th, 2024