THE 18th Amendment meant that the health sector has been returned to its original constitutional home in the provinces. This was a bold step undoing the centralised service delivery that, over the years, had fragmented local health systems.

Now the provinces have an opportunity to shape, test and implement innovations for improving health in line with local contexts. Service delivery needs vary greatly from the remoter districts of Balochistan calling for aggressive outreach services to the growing urban settlements of Punjab requiring private-sector harnessing towards the MDGs. The NFC award of 2009 provides fiscal space for funding such innovations.

To give credit where it’s due, health allocations have gone up in the provinces, both in nominal and real terms. However, the general rise in public-sector salaries, the doubling of Lady Health Workers’ salary by the courts, recurring floods and the upcoming shift of vaccines from the federal to provincial domain in 2015 will strain fiscal space.

The provincial governments must free up funds by re-examining existing allocations. All is not right, here. In Pakistan, health moguls are obsessed with building more specialty centres, medical colleges and expanding an already under-utilised health facility infrastructure. But we have enough infrastructure; it is the softer areas such as drug supplies, the repair of rundown equipment, primary outreach services and supervision that are overlooked in budget-making.

Less is also spent on preventive care. Pakistan has one of the highest levels of under-nutrition with more than 40pc children stunted, it is one of the last reservoirs of polio, and unlike its South Asian neighbours, is off-track on mother and child health targets. Chronic adult diseases are also growing but more cardiac centres will not help unless money is allocated for cost-effective early detection and managing hypertension and diabetes.

KP was the first province to kick-start health reforms, with a Minimum Health Service Package for the poor, commissioning NGOs’ services in hard-to-reach districts, and replacing fossilised polio control campaigns with the Sehat ka Insaf scheme.

Punjab soon followed, setting up the Punjab Health Commission for introducing quality standards, programming for 24/7 Basic Health Units and planning an ambitious health insurance scheme for affordable access to hospital care.

Sindh and Balochistan, while announcing an eight-year 2020 health strategy, have lagged behind in implementation. Sindh has seen a buzz of activity in recent months with the initiation of a public-private partnership scheme to boost under-performing facilities in remoter districts, the m-health monitoring pilot of health facilities, a healthcare regulation act, and several governance measures to revitalise the health department.

However Sindh needs a committed operational plan and visible change in curative and infrastructure-tilted spending priorities for the measures to materialise.

Balochistan faces challenges of access to health services in rural areas due to lack of roads, inadequate water, food insecurity and illiteracy. It recently started a health and nutrition programme to work out these problems but security issues may keep trained manpower away from remote areas.

So the provinces have indeed started out, but will they be able to deliver? Reform requires the stability of a seasoned team to carry it through across the health department as well as line departments such as finance and planning. So far, the constant transfer and postings of the senior civil service leadership has held the provinces back.

Further, reforms need a defined political face, a political vision tied to a party manifesto. In Colombia, the heath minister actively lobbied groups of senators to mobilise support for primary care. And President Obama while passing the Affordable Care Act had to face stiff resistance from private insurance companies and private medical providers.

A test of devolution will also be whether it can achieve grounded agendas on health. HIV control was pushed by nine international agencies but will non-championed causes such as hypertension, diabetes, cancer, depression etc find their way to the health agenda? A culture of accountability is needed to move in the right direction. Health indicators can deteriorate even as provincial health budgets grow.

The Pakistan Demographic Health Survey of 2012 provides a credible baseline of health targets. The provinces need time to bed down reforms and two years is not a test of devolution’s impact. However, the 60 years given to the federal health ministry cannot be given again. Let us see which provinces are able to get it right.

The writer is a health policy researcher at a private university.