Polio at the centre

Published in The News International on July 22, 2014:

Sometimes the rationale of a policy decision becomes apparent long after the actual decision itself. The imperatives created by the polio travel conditionality will help us understand why it was critical to re-establish Pakistan’s Ministry of Health (officially named the Ministry of National Health Services, Regulations and Coordination (NHSRC) under Pakistan’s Rules of Business).

Imagine the scenario had the WHO travel conditionality, involving polio vaccination for individuals travelling out of Pakistan, come into effect before the May 2013 decision to create the Ministry of Health. There would have been mayhem at the federal level, with confusion about responsibilities since federal mandates for health were fragmented in nine institutions during Oct 2011-May 2013, the former representing the time when the 18th Amendment came into effect.

To give a background, Pakistan’s Ministry of Health was abolished in 2011 by the 18th Amendment, on the notion that there was no need for federal ministries related to subjects that had been devolved, and since health was one of the 17 subjects devolved, its ministry was abolished. What was perhaps – inadvertently – not appreciated at the time was that there existed constitutionally-mandated federal responsibilities even for ‘subjects’ that were devolved. These fell under two Federal Legislative Lists (FLL), which are part of the constitution.

FLL Part I enumerated subjects purely under the federal government’s purview, for which the competent authority is the respective ministry/cabinet. The FLL Part II enumerates subjects of the federation, for which the Council of Common Interests acts as the competent authority. Relevant to polio, FLL Part I explicitly lists health information, cross-border spread of diseases and international treaties as being under the purview of the federal government, whereas coordination falls under the purview of FLL Part II.

Lessons from the period when health institutional responsibility at the federal level was fragmented (Oct 2011 to May 2013) indicate that the problems characteristic of that time – lack of coordination, interagency turf tensions, ambiguities about responsibility, difficulty for international partners, etc – would have further exacerbated during the existing polio travel conditionality.

All countries of the world that exist as federations have federal health institutions even if health is a fully decentralised subject. The responsibility for ensuring compliance with International Health Regulations (IHR), the world’s first legally binding agreement on fight against public health emergencies of international concern, is a central/federal responsibility in all.

The polio travel conditionality has been stipulated as part of the recommendations of an emergency committee the World Health Organisation director general convened under a mandate given under IHR. As a signatory, Pakistan has obligations, which it should and is fulfilling.

By committing to roll out vaccination of outbound travellers, the government took the right decision to play its part in attempting to halt the international spread of virus. Its capacity constraints and implementation limitations notwithstanding, the Ministry of NHSRC is one port of call where all stakeholders convened to forge federal and provincial plans in this regard. With responsibility for health in nine institutions (as it was post-18th Amendment during Oct 2011 to May 2013), this would have been a nightmare.

The creation of the Ministry of NHSRC does not mean that the centre should start stepping on provincial toes and start exerting its influence in areas that are provincial prerogatives. The functions of the 2013-established Ministry of NHSRC are strictly in line with the stipulations of the legislative lists in the post-18th Amendment constitution, which it must comply with. Ensuring disease security is part of its responsibilities, which it must step up to; there are many gaps in that regard which must be overcome as a priority.

But the fulfilment of travel restrictions should not detract Pakistan from the job of polio eradication and vaccination of children. Pakistan has many big ticket impediments in that regard. In fact, taken in the broader context of state governance, polio is a window to many of our daunting challenges. Despite these, the momentum must continue. The world is too close to the end game goal and Pakistan must not be labelled as the last remaining reservoir of poliovirus transmission in the world.

The writer is the president of the think tank Heartfile.

Email: sania@heartfile.org