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Amendment’s side effects

February 15, 2019

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The writer works at a multilateral development bank and advises on social and economic infrastructure.
The writer works at a multilateral development bank and advises on social and economic infrastructure.

HEALTH service reforms have failed to attract the ownership and attention necessary to deliver. This may have much to do with poor awareness of the economic impact of the health sector. The 18th Amendment in 2010 might have provided a workable legal framework for service delivery. But if the goal is to improve health outcomes, then the roles, responsibilities and rules of business need to be written and followed.

The 1973 Constitution did not include the ‘right to health’ as a fundamental right. The subject of health could only be legislated on jointly with the provinces under the Concurrent Legislative List. The latter was supposed to be revised by 1983 but was not. The federal health ministry was not structured or equipped for national functions; its approach was ad hoc and reactionary as seen in the building and managing of hospitals and running national programmes, with weak provincial ownership.

The 18th Amendment abolished the Concurrent List, and transferred health legislation and execution to the provinces, though the subject was still not considered a fundamental right. Medicines and issues pertaining to health service delivery were fully devolved, while those linked to medical education and human resource stayed within the federal ambit.

Devolution of health is a critical first step towards health reforms. Many countries simply alter institutional roles which serve little purpose in the absence of structural changes. Others launch universal healthcare systems, which prove ineffective as service delivery is not improved.

A national health policy developed with full provincial endorsement is a dire need.

The devolved health model, which is common across developed and developing countries, brings health providers closer to consumers, and improves health management and delivery. However, critical functions such as regulating health services, devising a national health policy, fulfilling international commitments and disseminating information and research still require unified ownership.

Many federal republics regulate health at the national level, so that federating units do not struggle when it comes to accepting each others’ standards or waste resources in duplicating efforts. There is strong justification for formulating health regulations and policy at the national level. For one, regulations aim to set standards in quality, cost and volume with regard to service delivery, medicines, education and human resource. Through the efforts of a few accomplished health and policy experts in the country, the creation of a Federal Ministry of National Health Services Regulation and Coordination in 2013 was crucial for these reasons. But although the need to regulate drugs and medicines was addressed through the formation of a drug regulator, the need for national regulations for service delivery remains unfulfilled.

Similarly, a national health policy developed with full provincial endorsement is a dire need. This is to establish core national values and principles, stipulate standards for provincial compliance and ensure social equity among the provinces. The policy must not be prescriptive regarding service delivery and financial matters — the provinces can strategise independently — but should provide guidelines for health information, disease management, international compliance, and trade in health.

The last national health policy in 2001 saw only partial implementation. A revision in 2010 was not followed through in anticipation of devolution. Then a National Health Vision in 2016, formed after much federal-provincial consultation, also fell through the cracks. Although not a policy document, the Vision put new constitutional roles in context, noted the challenges, and laid down a strategic vision.

In fiscal terms, the quantum of the provincial share has increased over the years. Once allocated, how much is spent on health is a provincial prerogative, since health financing matters are fully devolved. This includes devising strategies for pooling resources and procurement, as it is closely tied with service delivery. This is a proven model for cost-effective budgeting, planning and procurement. It also allows for a single-payer mechanism for attracting private-sector participation. The private sector already plays an oversized role in Pakistan’s health systems and can be engaged extremely effectively to the benefit of all stakeholders — the users, the governments and the operators.

With all its benefits, decentralised service delivery brings challenges in administration and execution capabilities. Add to this the coordination with national institutions and oversight. The devolved model bears fruit only with diligent, if gradual, capacity enhancement at district levels for managing the delivery of primary, secondary and tertiary care. The provinces’ main role should, therefore, be governance and procurement. District and local challenges are no secret, but the provincial role is necessary for robustness of the health reform construct.

The envisioned federal role must progress from the legacy of owning and managing hospitals. Ownership and management of hospitals and other facilities would be better in the hands of whoever is responsible for service delivery. But the constitutional list of federal subjects includes all agencies and institutions for research, professional or technical training or promotion of special studies. This leaves the door open for interpretation.

The Supreme Court recently handed back ownership and management of several hospitals in Lahore and Karachi to the federal government. It ruled that they were handed over to the provinces over an erroneous interpretation of the 18th Amendment, and that the centre reserved the right to build and run hospitals.

One respects the intricacies of legislation and their interpretation, but health infrastructure is unequivocally positioned better with the party manning the delivery nodes. If there are any weaknesses, the answer lies in developing institutional capabilities. Interestingly, anecdotal evidence suggests that delivery of care had in fact improved in all these institutions.

The raging debate over control of hospitals may aggravate further as other facilities could receive similar legal treatment. This would bring into question the willingness and motivation of those responsible for delivering health, leading to weaker delivery. The ensuing political and legal battles risk complicating an already fragile public health environment.

Federal institutions must focus on regulation and policy while provinces should spend their energies on improving strategy and delivery. A national health policy and regulations will provide momentum to health reforms, while capacity development at provincial and district levels will sustain them.

Devolution of health is a critical first step towards health reforms and Pakistan’s efforts are to be lauded. The challenge now is to move forward, not back.

The writer works at a multilateral development bank and advises on social and economic infrastructure.

Published in Dawn, February 15th, 2019