Published in The News International on April 30, 2006:

A news feature in The NEWS on April the 4th has outlined the NWFP Department of Health’s intent to launch a social health insurance scheme for the province. Aimed at improving access of the marginalized to health services, this is, in principle, a step in the right direction as it potentially offers a ‘health systems’ rather than an ad hoc solution. It is envisaged that if the strategy is appropriately structured, it can obviate some of the equity issues that have arisen from the currently prevailing tertiary-care-heavy health financing patterns. The articulation of this intent is also reflective of a bilateral donor agency’s proactive role in supporting health reforms and the strategic institutional support they have provided to the NWFP Health Sector Reform Unit, which amongst other things has primed policy makers to systems solutions. While the NWFP Department of Health needs to be lauded for it’s out-of-the-box thinking, it is also opportune to remind them of some of the overarching considerations that must be borne in mind while they embark upon mainstreaming social health insurance as a form of health financing in NWFP.

Firstly and to set the context, it must be recognized that social health insurance is just one component of a social protection strategy and must be approached within its framework. However, there are several design and implementation challenges in structuring a social protection mechanism outside the formally employed sector given that this necessitates overarching policy and legislative commitments, which are largely outside the scope of the health sector. It is imperative that the Department of Health recognizes the need for building linkages to address these issues earlier on so as to have this strategy housed, hoisted and pitched at the right level.  It would also be important to build broader linkages outside of the province to harness the strength within other similar initiatives. For example a Steering Committee has been constituted by the Planning Commission on social protection and work is presently underway by the World Bank, ADB and DFID to provide coordinated technical support to the Government of Pakistan in the area. Furthermore, the Asian Development Bank’s Country Strategy Programme for Pakistan (2004-2006) foresees technical assistance for social health insurance in 2005 with the objective of supporting the government of Punjab’s task force in its efforts in the area of health insurance on the one hand, and deliberating with the Ministry of Health on the subject, on the other. Clearly these are opportunities for coordinated planning.

Secondly, it would be critical for any de novo effort in the area of health insurance to link-in with and build on existing systems which finance health on insurance arrangements in NWFP. Notable amongst these is the Employees Social Security Scheme – which is a health insurance scheme, limited to the formally employed sector, where contributions can be made through salary deductions at source. It would also be important to learn lessons from failed experiences in the past such as in the case of the unsuccessful health insurance pilot in NWFP, which led to the withdrawal of funding support by World Bank and JICA.

Thirdly the establishment of a broad-based comprehensive mechanism for social protection, which can provide a safety net for the poor, would necessitate strategic attention to a number of institutional, fiscal and regulatory considerations. A health insurance institutional mechanism will have to be established and a legal and policy framework will have to be created for this purpose. Amongst the regulatory parameters that merit attention includes approaches to membership for populations and the extent of health cover to be provided; the latter is important given that government funds should preferentially be used for insurance models that cover for priority healthcare. This in turn highlights the need to define priorities and underscores the need for strengthening the normative health policy roles and bringing clarity to federal and provincial roles and prerogatives in health care delivery. Regulation will also have to ensure that this model reinforces and does not undermine the referral system.

Social health insurance also necessitates feasible and pragmatic organizational management to boost pre-payment and build enabling mechanisms for the development of a large pool of fund. A number of steps will have to be taken to achieve this objective. As a preliminary step, a sustainable Provincial Health Fund will have to be created with the government’s commitment to providing per-capita cost-sharing and the feasibility of channeling Zakat funds and philanthropic grants into such a fund will have to be explored. Such a fund will need to be protected by investment strategies, to ensure that inflation does not eat into its operational resources; it would be most interesting to observe how the current government of NWFP deals with this reality given their overarching policy positions on various issues.

Fourthly, social protection must be seen in a conceptual and ideological context. In Pakistan’s health care systems the state has traditionally attempted to provide health for all. Currently the State is attempting to redefine its role in service delivery through the introduction of alternative models of service delivery that mainstream the role of the private sector. This approach brings efficiency into the system but may raise concerns relating to access and affordability for the poor. And it is within this context that social protection becomes imperative. Conceptually therefore, social protection has to be pitched alongside other comprehensive health systems reform measures. What is happening in NWFP by way of channelling social protection as a mode of health financing and in Punjab by way of restructuring service delivery should ideally proceed in tandem within the same health system. Perhaps NWFP and Punjab Departments of health can capitalize on this opportunity for collective strategic thinking that may be applicable in both settings.

There can be no two thoughts about the need to pay careful attention to setting up a social protection system, given that Article 38 of the 1973 Constitution of Pakistan makes it binding for the state ‘to provide basic necessities of life for all citizens as are permanently or temporarily unable to earn their livelihood on account of infirmity, sickness or unemployment’. Social protection is also an imperative in view of the increasing role of the market mechanism in the delivery of health service as a whole and the mainstreaming of private sectors role in state-owned infrastructure more specifically. Within this context, NWFP’s initiative is both timely and needed. However it would need long term planning, strategic positioning and careful structuring within an overall health reform context in order to fly.

The author is the Founder President of the NGO Heartfile and Pakistan’s Health Policy Think Tank. E mail: sania@heartfile.org

Published in The News International on April 23, 2006:

Recently, a national strategy has been approved for revamping the ‘Primary Health Care System’ with structural changes envisaged at the District level based upon the results of a pilot experience in Punjab. The strategy aims to restructure the first tier of the health service delivery infrastructure – the Basic Health Units (BHUs).

By infrastructure standards, Pakistan has one of the largest health service delivery networks at a basic healthcare level. This comprises of 5301 BHUs, each with a catchment population of 10,000 to 20,000 and 552 Rural Health Centers (RHC0s – a step above the BHUs. However in reality only 70% of the BHUs are currently operating; their infrastructure is used by other sectors in many cases and a vast majority is underutilized with a recently reported average daily turnover of 20 to 30 patients a day. The low turn-over observed at these sites is attributable to low-quality inputs as is evidenced by staff absenteeism, infrequent availability of essential medicines, poor attitude of staff and other issues such as geographic access and out of pocket payment for supposed free services. As a result, the average cost-per-admission and outdoor-contact incurred does not justify the present level of investment in infrastructure, staff and equipment in these sites.

Given these considerations, a strategy which aims to restructure BHUs is, in principle, desirable given that BHUs in their present form are – put simply – underutilized and unsustainable. However, this strategy should pay careful attention to a number of steps that need to be taken in tandem in order to ensure its success and long term viability.

Firstly, the potential within a pilot intervention to be up-scaled successfully depends on the overarching policy and procedural framework within which it is set. It is therefore important to develop a regulatory framework and a system of combined governance in the new contractual arrangements for ensuring balanced power relationships with careful attention to accountability and sustainability-related concerns. Once such parameters are in place, a core prerequisite to contracting out services is to develop operational frameworks. Selection criteria must be specified, procedures for recruitment must be articulated, guidelines on ethical and administrative matters should be developed and procedures for developing price negotiations and contracts should be laid down and made publicly available.

Secondly, within the context of contracting out, it has to be made sure that public funding is used to ensure that poor people who access health services are not disadvantaged or discriminated against and conscious safeguards have to be built for this purpose. This links in with the need to develop comprehensive Social Safety Nets, which scope beyond what is currently available through Zakaat and Bait-ul-Mal. Such frameworks must structurally safeguard the interests of the poor and develop waiver and exemption mechanisms for the poor in the event of a fee for service being introduced in health care facilities. Higher authorities should continue to have a role in order to ensure that the poorest have access to quality services.
Thirdly, notwithstanding major issues in their present form, BHUs and RHCs serve as community hubs for the delivery of preventive and promotive services such an vaccination and control of infectious diseases; these have to be delivered by the State as public goods. In addition, BHUs also serve as training hubs for Lady Health Workers – Pakistan’s field force of grass-roots level health care providers, which deliver priority health services at the grass roots levels. Within this context, the mechanisms of delivery of these essential public health services and the role that the Government needs to play to deliver them, needs to be procedurally clarified in contracted-out arrangements. This highlights the need for a conscious and concerted effort to mainstream preventive, promotive and disease-control-related activities in these new contractual relationships. The State must define mechanisms for the delivery of health-related public goods and priority services and its new operational role in these models. Such reforms should also assess the feasibility building incentives for promoting preventive practices in the communities these serve; measures such as distribution of iodized salt, free bed nets in malaria-affected rural areas and branded soaps can create added interest in preventive activities. Partnerships with NGOs can be rewarding and fruitful in this connection given the outreach advantage that they bring.

Fourthly, restructuring must integrate community co-management at a basic healthcare level. The concept of having a community-based body at the facility level to oversee management and quality issues is now realistically possible, given the focus on community development and mobilization as part of the devolution initiative. Community Citizen Boards, Village Health Committees and other grassroots level organizations – mandated as part of the district devolved system – can either play a role in the setting up of co-management boards, overseeing them or serving as one. Many measures can be taken to ensure transparency and garner greater community support for such initiatives; for example, user fees can be made public and prominently displayed. Targeted capacity-building in the area of financial management and control, account keeping and management should be promoted in order to enhance the capacity of communities to serve this role. The feasibility of utilizing village co-management structures for record keeping (as in the case of vital registration) and strengthening the referral systems also needs to be explored.

In the fifth place, decisions to revamp the primary health care infrastructure need to be locally-suited. The model centered on ‘contracting out’ appears to be suitable in some areas owing to the concomitant presence of NGOs with the ability to deliver in such arrangements. However in other provinces/districts, the feasibility of contracting out vis-à-vis other revamping options – transferring management to lower levels of government or maximizing efficiency within the existing system – also need to be explored by determining whether the existing system can yield results if granted administrative and financial autonomy. In addition, the recently established contracting arrangements should serve as empirical models from which useful lessons can be drawn with relevance for broader outcome-orientated arrangements.

The strategy to restructure basic health care units also brings to the forefront many questions of overarching relevance – questions that relate to mandates, prerogatives and responsibilities and queries that have to do with the federal-provincial relationships and prerogatives in policy making. Perhaps BHU restructuring can also be used as a test case to bring clarity to some of these overarching issues.

The author is the Founder President of the NGO Heartfile and Pakistan’s Health Policy Think Tank/Forum. E mail: sania@heartfile.org

Published in The News International on April 09, 2006:

Civil service reforms need to be an integral part of social sector reform processes if sustainable solutions to currently existing issues within the ambit social sector service delivery are envisaged. Within this context, there seems to be some justification for the perception that civil service reforms may finally be part of a mainstream agenda in Pakistan. This is evidenced by the initiation of processes such as the creation of a Committee for Civil Service reforms, the establishment of a Civil Service Reform Unit in the Establishment Division, launching of the Professional Development Agenda and the more recent announcement of the reform package for introducing good governance in the country by the Ministry of Law and signaling the importance of this area of reform by soliciting help from the multilateral development agencies. However, given that this is not the first time efforts are underway in this area, tipping the balance from the hope-to-hype equation will depend on the manner in which a strategic approach prevails – both in intent and in actions. Within this context, five points are worthy of consideration.

1. Bridging the colonial-contemporary lag:  modeled on the colonial system, the core functions of Pakistan’s civil services are administrative control, collection of revenue, exercising control through regulatory checks and in the case of its expanded definition to public services, active engagement in service delivery. Exceptions notwithstanding, this model has little relevance to the problems of the public sector today which relate to harnessing the entire resources of the economy towards the goal of development. The public sector’s limitations – owing to lack of resources and management issues – therefore underscore the need to develop interface arrangements, with organizations that could facilitate achieving this goal. Such interface arrangements, which have to do with establishing partnerships with the private sector for providing sustainable outcomes warrant a paradigm shift in reconfiguring the role of the public sector. This would entail ‘exercising administrative control’ through participatory decision-making in evidence-based frameworks, ‘enforcing regulation’ through setting of standards, an unbiased approach to ensuring compliance with these standards and assurance through strengthening peer organizations as we move to new models of financing and delivering services and implementing frameworks for public-private partnerships. This would require major institutional changes in the present arrangement of civil service operations. Reconfiguring to meet this goal is the first challenge that the civil service reforms will have to address. 
2. The incentives-accountability-performance nexus:  many a times, civil service reforms are considered as being synonymous with incentive building. Clearly incentives – albeit linked to performance – must be a priority to bridge the current disparity between the current public-sector salaries and the public-sector-accepted-market-rate for professionals, which is evidenced by what consultants ‘within’ the public sector are offered. However, it must be recognized that lack of capacity is clearly a constraint on the ability to act on these incentives. This highlights the need for instituting appropriately tailored capacity-building programs in tandem with Recruitment, Promotion and Pay and Pension Reforms currently on their way to being implemented. However, capacity building must be needs-based and targeted. The current three-pronged capacity building initiatives inclusive of the Professional Development Program, the Executive Development Program and revamping of the existing training institutions must pay careful attention to the local context of capacity building at the strategic and operational levels.
   
3. Building capacity for performance must be approached in tandem with creating a milieu to enhance performance and the incentive-performance link completed by factoring-in accountability into the equation. This highlights the needs for institutionalizing transparent managerial audit within public sector institutions at various levels. Careful attention should also be paid to developing appropriate instruments for assessing performance. Currently, the Annual Confidential Report is the chief instrument for assessing the performance of public officials in Pakistan; however it is widely perceived that it is not an effective instrument for promoting accountability and is also reportedly used as a means of exploitation.
4. Civil service reforms to reorient institutional culture: civil service reforms should not just be about incentives for performance, about reforming a line for service or about compensation of bureaucrats. The reform process must focus on governance in its broader context and enhancing efficiency in the delivery of public services in a conducive institutional culture – a culture geared in the outcomes-efficiency context rather than being focused on short term gains. Therefore, in addition personnel management reforms which go beyond personnel action and set standards for performance and build mechanisms for their assessment and rewards there is a need to pay attention to transparent regulation and minimizing vested interests, political benefaction and interference in decisions, particularly in relation to recruitment, transfers and disciplinary actions as these are  perceived as an impediment to efficiency within the system, in addition to being a demoralizing factor within the public sector.
5. From civil service to public service reforms:  the current focus on ‘civil servants’ within the context of ‘service reforms’ is understandable given that it is seen as an instrument for mainstreaming second generation macro-economic reforms. However if this is to translate into improved social services delivery, other cadre and ex-cadre categories of public servants must be brought within its ambit. One of the challenges posed to service delivery in the area of health and education relates to human resource – low numbers for certain categories, migration of skilled workers, misdistribution of workforce, staff absenteeism, dual job holding, lack of motivation to perform and the proverbial brain drain are manifestations of the lack of economic opportunities and incentives often complicated by other factors. These must be at the heart of a strategic reform process rather than ad hoc measures.
6. Devolution vis-à-vis Decentralization: Civil service reforms to improve governance must also have an added context given that social service delivery is now devolved to 100 districts governments who have little experience of such responsibility in the past. This underscores the need for the reform efforts to pay close attention to two processes. In the first place, granting district autonomy and authority should proceed on a sliding scale with capacity as a due consideration. In the second place, it is important to build appropriate safeguards against several issues which have been brought to attention during the initial years of implementation of the Local Government Ordinance of 2002. For example, Provincial Governments still retain influence over establishment decisions and have considerable de facto control over recruitments, career management, transfers and termination. It has also been shown that

political and administrative ‘decentralization’ has also paradoxically created ‘centralization’ of some functions within the district itself as the DCO now has centralized control over all the staffing decisions vis-à-vis EDOs. In addition discrepancies in reporting relationships are also worthy of note in the context of the need to address them.

Many reforms measures are presently on their way to being structured and implemented in many sectors – of these the Police reforms, Judicial reforms, and reforms introduced by the Public Procurement Regulatory Authority and the National Anti Corruption Strategy have been announced and there may be others, in the pipeline. A reform agenda in the health sector has also been tabled by the Pakistan’s Health Policy Forum. However it must be clearly understood that the success of all these reform measures and others that may be in the pipeline will depend not only on the manner in which they pay due attention to human resource solutions – within the civil service – but also within the broader context of human resources. The aforementioned five points have been articulated with a view to catalyze a long term vision in line with this approach.

The author is the Founder President of the NGO Heartfile and Pakistan’s Health Policy Think Tank. E mail: sania@heartfile.org/Forum and the author of the Gateway Paper. E mail: sania@heartfile.org