The devolution debate in Pakistan has raised a variety of important issues for the health system. There appears to be a clear consensus in Pakistan that devolution to the provinces is an important advance but it has created several problems that suggest the need for some central agency to address national health issues. There are no ideal types of decentralization and each country needs to select the model that is most appropriate and politically feasible for its situation. Nevertheless, it is likely that a review of international experience in Canada where considerable devolution to the provinces might hold some lessons that would address some of the problems. One of the important lessons is that a well-structured central health ministry at the federal level with clearly defined functions can be an effective coordinator of both provincial and national interests. Secondly, it show that an agreement on principles for health benefits that are supported by federal funds can make for a more equitable health system coverage while respecting provincial priorities. The Forum of Federations http://www.forumfed.org is currently preparing a review of federal experiences in selected countries around the world. Its reports next year should provide additional lessons from other countries that can inform Pakistan policy on decentralization.
Thomas Bossert, Ph.D.
Director International Health Systems Program
Harvard School of Public Health