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Civil Service Reforms–the move from hype-to-hope

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

The Gateway Paper – towards a health systems reform

Published in The News International on March 19, 2006:

Released on January 9, 2006, the first publication of Pakistan’s Health Policy Forum (PHPF), the Gateway Paper entitled “Health Systems in Pakistan – a Way Forward” is set within a broad context. A context relevant to health on the one hand and one that cross cuts with broader social sector issues, inter-sectoral processes and mainstream governance and sustainable development challenges, on the other.

Pakistan’s Health Policy Forum has recently been created as the country’s first health sector Think Tank with the overarching mission of providing an independent voice for the promotion of the health and well-being of the country’s population. Its specific objectives are to review and analyze health ‘policies’ and ‘systems’, assess gaps and offer solutions to address impediments and to catalyze change through technical and policy support. The Forum/Think Tank is envisaged to play an important role in promoting accountability of decisions by educating the civil society in the dynamics of health care delivery, policy and financing; mobilizing their participation in the health policy process and mainstreaming the voice of the civil society in decision making – an attribute critical to strengthening the ‘societal’ political culture. An initiative of the NGO Heartfile, Pakistan’s Health Policy Forum is the largest grouping of stakeholder organizations and individuals in the health sector. (http://heartfile.org/hpf.htm).

In a true sense, the Gateway Paper is a gateway or opening of new effort to address the pressing health needs of the country. The intent is to articulate the raison d’être for health reforms within the country, propose a direction for reforms and emphasize the need for an evidence-based approach to reforms. The Paper has also been structured to assist PHPF with the setting of its priorities and to guide its analytical and technically supportive functions needed to support health systems reforms in the country.

Making a strong case for ‘systems reforms’, the Paper provides linkages with Pakistan’s health systems and its policy cycle providing a strategic view on how they can work better together. The Paper reviews issues and proposes solutions for the basic functions of health systems – stewardship, financing, service provision and inputs. It also discusses three distinct interface areas critical to performing these functions; these are the federal-provincial interface, decentralization and the public-private interface. In addition, the Gateway Paper also focuses on several overarching health paradigms such as health promotion, legislation, research and the inter-sectoral scope of health as singular areas, with the understanding that each of these is cross-cutting in its scope. In its Finale, the Gateway Paper synthesizes recommendations from each health systems domain discussed in the paper and presents a viewpoint on the proposed directions for evidence-based health systems reforms in Pakistan. The proposed reforms point in the direction of four broad areas namely, reforms within the health sector, overarching reforms, reconfiguration of health within an inter-sectoral scope and generating evidence for reforms.

Within the health sector, the proposed reforms focus on strengthening the role of the State as the principal steward of the health system; setting of priorities for the use of public funds and definition of priority services to be provided universally and developing alternative service delivery and financing options at the basic healthcare and hospital levels. Within the context of the latter, this includes community co-management and contracting out arrangements for basic health care, maximizing efficiency in the same system or transferring management to lower levels of government – an option complementary to the administrative arrangements within decentralization – whereas with reference to hospitals this involves granting autonomy at a management level and the introduction of cost-sharing at the level of financing. The paper also makes a strong case for building the capacity of and effectively deploying human resource, establishing a conducive and rewarding working environment and initiating measures to redress imbalances with regard to the existing staff.

At an overarching level, three proposed directions of reform have been articulated; the first involves establishing a legal, policy and operational framework for public-private partnerships in order to foster arrangements that bring together organizations with the mandate to offer public good on the one hand, and those that could facilitate this goal through the provision of resources, technical expertise or outreach, on the other. The second includes building conscious safeguards in order to offset the risk of creating access and affordability issues for the poor in the new service delivery arrangements which mainstream the role of the private sector. This includes the establishment of social health insurance as part of a comprehensive social protection strategy that scopes beyond the formally employed sector, providing a widely inclusive safety net for the poor and the strengthening of waiver and exemption systems in order to provide subsidies to treat poor patients. And the third focuses on institutionalizing civil service reforms centered on good governance, accountability, crackdown on corruption, factoring in of performance-based incentives, mainstreaming managerial audit and building safeguards against political and external interference.

The proposed reforms within an inter-sectoral scope entail developing alternative policy approaches to health within its inter-sectoral scope with careful attention to the social determinants of health and several contemporary considerations that influence health status – in other words, broadening the ‘healthcare system’ to a ‘health system’. Most of the available information about Pakistan health systems refers to provision of and investment in health services curative more than preventive and palliative – directed at individuals and populations. This constitutes the healthcare system; however a health system is much broader; this underscores the need for health to be viewed in its inter-sectoral scope. It is well established that many factors which determine health status range much broader than those which are within the realm of the health sector. Health cannot be extricated from the political, economic, social and human development contexts. It is well established that liberalization of international trade, global infectious disease pandemics, natural disasters and humanitarian crises can be detrimental to health outcomes as can be changes in international cooperation and geopolitical situations which can have implications for the manner in which health is resourced in a country such as Pakistan.  The proposed reforms in ‘health’s intersectoral scope’ necessitate redefining targets within the health sector in order to garner support from across various sectors and setting these targets within an explicit policy framework in order to foster inter-sectoral action. In addition this also warrants the creation of intersectoral agencies that concentrate on prevention and health promotion at multiple levels – legislative, ministerial and others as necessary; development of dedicated provincial agencies that implement such programmes and overarching policy and legislation for health promotion.

The fourth area of emphasis is on generating evidence for reforms. Health reforms must be firmly grounded in evidence, which in turn, should be utilized for appropriate modifications as the reforms get on their way to being implemented – an approach, which allows action accompanied by rigorous evaluation and up-gradation of programmes and policies. The individual components of the health reforms being proposed also mandate robust evaluation; this can allow the evaluation of competing concepts and can, therefore, guide the up-scaling of appropriate initiatives for broader systems-wide adoption. This is critical to the development of well-structured and sustainable service delivery and financing mechanisms. The Gateway Paper outlines a list of priority areas where health policy, systems and operational research should focus in order to yield evidence critical to the success of the proposed reforms. The Paper also outlines policy frameworks, institutional mechanisms and norms and standards required to support the reforms it proposes thereby providing a clear linkage of conceptual thinking to practice.

The proposed reforms outline the need to strengthen systems and institutions, build capacity and foster a greater commitment to basing decisions and actions on evidence. However, health cannot be extricated from the political, economic, social and human development contexts and reforms within the healthcare system and the health system at large cannot be separated from several overarching processes. Poor regulation, gaps at the governance and management levels and lack of appropriate incentives contribute to lack of efficiency, staff absenteeism and abuse; these are compounded by lack of accountability within the system and lapses in social justice, which in turn cannot be extricated from overall macroeconomic and social development. Sustainable progress at the health systems and healthcare systems levels, therefore, depends to a large extent, on the manner in which progress is made in all these areas in addition to human development, the overall rate of economic growth and improvements at a governance level. With the current trend of economic growth, it is important to pay close attention to these overarching processes as these are critical to impacting social sector indicators within the country. Health reforms can undoubtedly be an entry point for these structural changes

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

Avian Flu – the short and long term contexts

Published in The News International on March 05, 2006:

Given that diseases such as the Plague, SARS, HIV/AIDs and Avian Flu do not respect national boundaries, the news of Avian Flu in our immediate neighborhood, left a slim choice between treading the prevent-prepare-control options a week ago. However its detection on an NWFP farm yesterday, made choices much clearer. Ever since Avian Influenza (H7N3) hit Pakistan in 2003-04 and was subsequently curbed at source in the agriculture and health sector through implementation of animal and human health surveillance, disease control and mitigation measures, some level of gearing up for another outbreak had been witnessed. Evidenced by news and other forms of reporting, efforts included the establishment of surveillance laboratories equipped to diagnose bird flu; enhanced allocations for strengthening surveillance and emergency preparedness and clinical, serological, and virological surveillance in migratory birds from different parts of the country. It is hoped that these investments will pay off given the recent emergence of the virus in NWFP.

However, the situation specific to Avian Flu and the earlier experience relating to the health situation consequent to the October 8 earthquake raise several policy questions for medium- and long-term planning. These relate to striking a balance between the short and the long-term measures; the capacity within the system to respond to a health crisis; the level of preparedness of the health systems to deliver emergency services; and most importantly, the extent to which a credible cost-effective and equity-focused analysis supports investments in these within a long term context. Three overarching issues of concern have been flagged here particularly with regard to medium and long-term planning.

Strengthening health systems:  the threat of the Avian Flu looming has once again highlighted the need for strengthening what is generally the ‘invisible’ in the social sector – institutional systems and capacity. Decades of focus on programme-based service delivery and an over-emphasis on infrastructure development have led to neglect at the health systems level. On-ground analyses indicate that the success of any health programme depends on the robustness of the health systems; indeed one of the markers of such systems’ strength is the degree of preparedness and responsiveness to public health emergencies.  Indeed many of the measures necessary to address the current challenge—particularly at the health sector level—are embedded in systems-level solutions.  For instance, bulk purchase of anti-virals for people and vaccines for birds links in with procurement mechanisms in the public sector; their inventory management and distribution from central base/s to the grass roots level is dependent on a friction-less Federal-Provincial-District service delivery interface; the missed opportunities to deliver them through private sector health care providers ties in the need to leverage on the private sector to deliver state-mandated-health-related public goods and the ultimate provision of these vaccines and medicines at the grass roots levels forms an integral part of the service delivery potential of basic health infrastructure.  Furthermore, designating hospitals for the treatment of the infected and equipping them to treat and care for affected individuals links in with issues of efficiency and sustainability.  Prompt dissemination of standard treatment guidelines and training health workers in such diseases ties-in the role of continuing medical education programmes – currently nonexistent in the country.  Systems-level solutions also need to be placed in the right structural, fiscal, and regulatory parameters; for example, another Avian Flu imperative which involves identification of laboratories for testing human and animal blood samples highlights the need for establishing a legal system that mandates the notification of diseases and regulates laboratory practices.

Strengthening systems must also proceed in tandem and with careful attention to the state asserting a stronger normative role. In the present situation guidelines for prevention and control of human cases of Avian flu influenza disease have been established by the National Institute of Health in collaboration with international partners; these must be widely disseminated.  In addition, the State’s normative role in this situation needs to be further augmented within the broader context of the prevention- and control-focused methodologies and instruments.

Health Disaster Preparedness: secondly crises – natural or manmade – are marked by increased level of death and suffering and put health systems through complex and unique emergencies.  Health policies should, therefore, incorporate disaster planning within their realm with a focus on preparedness, response, and recovery fostering collective responsibility to act effectively and enabling the development of new mechanisms and systems for health governance in the wake of these considerations.  A National Health Disaster Preparedness Plan developed within an overarching disaster management framework is therefore, a strategic imperative; this must pay careful attention to mapping human resources and infrastructure, inventorising demands and developing contingency plans.

Health’s inter-sectoral scope: thirdly, it is well established that much of the scope of the public health work is conventionally placed outside the medical care service and that factors which determine health status range much broader than those which are within the realm of the health sector. Environmental changes such as global warming and changing ecosystems may have implications for spread of disease and its control; mass damage by biological weaponry is a possible threat to civil infrastructure with serious public health implications; natural disasters raise public health issues of great significance; humanitarian crises as a result of conflict and acts of terrorism are known to impact health status of those affected and global pandemics such as the recent SARS and Avian flu epidemics have cut health across the global economy and allied sectors, taking health concerns to a completely different level.

It is therefore imperative that alternative policy approaches be developed for health within an inter-sectoral scope. This necessitates a redefinition of objectives and targets within the health sector in order to garner support from across the sectors. However, these need to be set within a more explicit policy framework in order to foster inter-sectoral action. Relevant ministries and organizations need to own this approach and participate in a manner, which is mutually supportive of common goals. Support for this should come from the highest ministerial level in each instance and should also reflect the support of the Cabinet. Within this context, Avian flu is a case in point which ties the role of many government departments and the private sector.

With the threat looming, it is understandable that policy objectives must focus on short term planning; as part of such efforts mobilizing the public as a key partner in beating the disease, measures to compensate poultry owners and encouraging them not to conceal a bird flu outbreak by providing specific incentives, and formulating a short-term incident management program with clear designation of roles and responsibilities and a command and control system to effectively minimize loss in the event of an outbreak are therefore justified.  However, daunting as they may seem – these should not prevent institutionally sustainable action set within the long term perspective given that this would be critical to strengthening the systems’ ability to cope with such disastrous events in future.

The author is the founder and President of Heartfile and Pakistan’s Health Policy Forum. E mail sania@heartfile.org

Pakistan Medical and Dental Council – strategic imperatives

Published in The News International on February 08, 2006:

Recent controversies around the Pakistan Medical and Dental Council (PMDC), the efforts presently underway to break the resulting stalemate and more topically offered solutions now favoring a major overhaul highlight an opportunity to flag some fundamental questions about the role of this institution. Mandated with a normative and regulatory role within the ambit of the medical profession, PMDC is a statutory autonomous organization. The PMDC Ordinance of 1962 and the subsequent amendments introduced in 1967 and 73 provide a policy framework enabling it to set standards of medical education, register practitioners and accredit academic medical establishments. But is this all that needs to be within the PMDCs remit? Or should its role be broader given that this is the only body that regulates the medical profession? If considerations of protecting, promoting and maintaining the health and safety of the patients are brought to bear – as they should given that they are the cornerstones PMDC’s code of ethics – perhaps there is a need for revisiting its scope. These bring to the forefront many other issues such as assessment of performance and accountability, credentialing of doctors through peer review processes, continuing medical education as a prerequisite to maintaining a PMDC license, accreditation and quality assurance mechanisms for private health facility infrastructure and effective adjudication of complaints. Currently proposed health reforms make a strong case for creating appropriate institutional mechanisms for this purpose; for example, the recently released Gateway Paper of Pakistan’s Health Policy Forum, makes a case for the creation of a National Council for Health Care Quality, Peer Review Boards, and institutional mechanism for Continuing Medical Education to support the reforms it proposes. Within this context it needs to be determined whether PMDC can perform these roles or is there a need for configuring independent institutional mechanisms for this purpose and in the case of the latter what relationships will these have to the PMDC given the cross-cutting mandates.

Expanding the scope of regulation – within or outside of PMDCs domain and presumably through autonomous institutes – raises the question of who gives autonomous institutions a regulatory mandate. Who enforces it and makes them accountable and in what manner? Granting autonomy to a regulatory institution such as the PMDC is quite unlike granting autonomy to service delivery institutions such as hospitals where appropriate policy and operational framework and mainstreaming of the market mechanism can serve the debatable core purpose of making them efficient and sustainable. However that is not the case with an institution whose core functions are normative and regulatory. Regulation and standard setting are the functions of the State per se. This is even more critical in a medical education context, which is not – and cannot be – a private sector forte. However this does not imply that an institution to regulate the medical profession cannot be autonomous. A certain level of autonomy in terms of ensuring that the voice of all stakeholders is expressed in decision making and management may actually be necessary to ensure that regulation does not become coercive, that standard setting is reflective of an appropriate expression of all perspectives and that the enforcement of these standards and norms is being overseen by a participatory process. However autonomous institutions in the truest sense work most efficiently and transparently in institutional and societal cultures that have fully matured to the realties of self governance. In settings where there are gaps at this level, professionally led regulatory institutions should be configured in a public sector-professional partnership and must not be separated from State oversight, the limitations of the latter, notwithstanding.
Given these considerations, four areas of reforms are proposed within the PMDC and PMDC allied-regulation context:

The first area of reform relates to PMDC’s governance functions and operations. In this area, there is a need to clearly separate the governance functions of the Council and its functions which relate to case work and adjudication of complaints with appropriate safeguards – not just byelaws but also their implementing mechanisms – to ensure the upholding of evidence in decision making and protection against interference from vested interest groups. In this area of reform, the terms of engagement of this autonomous institution, the level of State oversight and its mechanisms and the accountability paradigms need to be articulated with clarity and due representation of stakeholders ensured. There is also the need to bring greater clarity in the means of conflict resolution. This links in with some overarching questions about the mandates of the Senate and Parliamentary Standing Committees on health and how these relate to the operational scope of health policy implementation within Pakistan.

The second area of reform relates to revisiting its existing mandate. Here the feasibility of introducing conditionalities for retaining the PMDC license should be assessed. This can either be through the introduction of revalidation – or demonstration by doctors that they meet the standards required for continued registration – or through incorporating a Continuing Medical Education program as a prerequisite for maintaining a PMDC license. Ideally it should be a combination of both. There is also the need to assess the feasibility of revising the examination procedures and creating a national examination board.

In the third place it is critical to mainstream its role in the evidence and the policy cycle. By virtue of its core role to register medical practitioners, PMDC holds the largest dynamic database of healthcare providers in the country. There is a need to synthesize this ‘information’ into ‘evidence’ for policy-level decision-making with respect to human resource quantitatively from the supply and demand perspective, qualitatively, and with respect to their effective deployment. PMDC owned-data can potentially yield evidence in several areas. These may be relevant to personnel management reforms which should ideally go beyond ‘personnel actions’; pragmatic human resource solutions for public sector doctors with relevance to dual job holding and coercive bans on private practice; dealing with quackery, the effect of privatization of medicine on the quality of education and an analysis of the demand for these institutions vis-à-vis self financing schemes for existing public medical institutions.

And in the fourth place, drawing an analogy with the UK’s General Medical Council and connecting with the overall context of PMDC’s ethical principles and standards which determine its responsibilities, a serious thought must be given to the scope and scale of PMDC role within the context of broader considerations relating to regulating the medical profession. If the purpose is to protect, promote maintain the health and safety of the public, then there is a need to expand the scope of regulation – within PMDCs ambit or outside of it – to encompass considerations of performance assessment, credentialing of doctors, continuing medical education, licensing and accreditation of service delivery facilities, quality assurance mechanisms and the monitoring of errors. These considerations underpin the viability of the reforms being introduced in the health sector – at the level of delivery of services through basic health care facilities or hospitals or the financing of health care. Whether the PMDC can be restructured for this role or whether other institutional mechanisms need to be configured must be the subject of strategic deliberations.

The author is the founder and president of the NGO Heartfile and Pakistan’s Health Policy Forum – a health sector think tank. E-Mail: sania@heartfile.org