Published in The News International on March 22, 2010:
The Ministry of Health has stepped up efforts to enunciate the National Health Policy 2010 and bring the process, which commenced with the initiation of a Health Policy Task Force in 2008 to fruition since the availability of donor resources has been made conditional on pronouncement of a health policy.
Development of a new vision for a health policy is a complex process in Pakistan’s context for a number of reasons. Pakistan’s mixed health system has many systemic flaws, therefore, a reform agenda must be implicit in a health policy. The diversity of health systems domains and the range of health actors and institutions need to be factored into consideration in the process. The complexities of health governance, multiple funding sources for health, and external drivers that impact health need to be addressed while framing the policy. Directions for service delivery arrangements that can enable universal coverage for a set of interventions have to be articulated within the rubric of which the public-private-interface dimension has to be addressed. Then there are policy positions with regard to health information systems, health workforce at various levels, and the mechanisms and means of health financing, which need to be stated. Broader structural dimensions impacting the health system—decentralization, mechanisms of social protection, labour market interventions and health’s entry points to reduce poverty—are other considerations. A health policy additionally has to be alive to the realities of globalization, disease security and health risks as a result thereof, the harmful effects of trade, and the aid effectiveness agenda.
Given the diversity of domains and the possible policy options within the remit of each, there is a risk that the policy may end up being a concoction of jargons stated as policy approaches. If the draft, currently under preparation ends up with such a construct, an opportunity will be missed.
As a key social sector instrument, a ‘national’ (federal) health policy must have certain features in order for it to have any meaning in the context of some fundamental shifts, which are taking place at the broader state level. There is a movement towards judicialisation of rights and the Constitution is being amended; a call for universal coverage reform could be linked to constitutional changes. Provincial assertions for a more autonomous status are now pressing and indications that the federal government might finally relent are evidenced in the National Finance Commission Award 2010 and statements that the Concurrent List might be scaled down. This, therefore, could be the right time to re-examine the federal government’s role in the health sector. Moreover, there is pressure on the government to scale down recurrent expenditures in order to reduce fiscal deficit and an International Monetary Fund-conditionality in line with this has recommended that the ministries of Health and Population be merged. If this is being taken seriously, as official statements indicate, the enunciation of a national health policy—and a population policy, which incidentally is being framed at the same time—is the right opportunity to cascade political intent into a policy instrument. Furthermore, as the fate of the district government system is now fully in the hands of the provinces, it doesn’t make sense to give explicit across-the-board guidance on how services delivery will be managed.
It is well known, constitutionally decreed and frequently recalled that health is a provincial subject, but when it comes to the pronouncement of polices and structural decisions, a top-down approach is adopted with the tendency to micromanage, implicit. If that is adopted this time round in the case of the national health policy, the whole purpose of the exercise will be defeated. There has been a long standing history of federal heavy handedness in health. Now is the time to remedy that.
That said, there are some important purposes that a national health policy can achieve and areas where the mandate and the comparative advantage of a federal role in health can be capitalized through a federal policy instrument. Three areas are being outlined in this regard.
One, since resource mobilization is predominantly a federal mandate, a federal policy should deliver a plan for incremental increases in public sources of financing and revenue earmarking for health based on a provincially-agreed per-capita cost, which is considered adequate for delivering essential services. The policy could integrate allocations from the general revenue pool to support common health objectives, which is currently not the case. A federal fiscal tool could develop incentives for provinces and districts to enhance health allocations. Rather than micromanaging the type of insurance schemes to be pursued, the federal government could signal an intent to broaden the base of pooling through legislation, whilst leaving specific options open for provinces to pursue. Most importantly, the fiscal strategy central to the policy can be an opportunity for the federal government to off-load its service delivery responsibilities inherent to administrating hospitals and the national vertical public health programs, which have crowded out the space for normative work—a ministry’s core responsibility.
Second, a national policy must spell the principles of service delivery, in addition to the broader principles of a health policy. Several management reengineering experiments are being conducted by health departments of various provinces, and other state institutions. Pakistan’s primary healthcare infrastructure is a thriving laboratory. These innovations can only bear dividends if evidence is factored into planning in line with stated principles to ensure that state investments are targeted to serve the equity objective. A national policy assumes great importance in negotiating these principles and safeguards, which can then become benchmarks for service performance nationally, whilst fully giving provinces the prerogative to choose locally-suited service delivery options.
Thirdly, there are important federal roles in health, where the policy must state its position loud and clear. The strategic area of consolidating evidence and information and bridging gaps in Pakistan’s health information system is one of them and is an increasingly important area in view of threats from emerging and re-emerging infections in Asia. Implementing globally binding agreements, the Framework Convention on Tobacco Control and the International Health Regulations 2005 is another important area as are the myriad of policy dimensions relevant to trade in health and coordinating donors’ contributions. Medicines and Workforce policy in health is a known federal forte. The federal government also has an important role in health regulation with dimensions relevant to regulation of price, volumes and quality in the domains of service delivery, medical education and pharmaceuticals. Its regulatory role becomes important because of provincial limitations in capacity in these areas.
The policy must be clear on these aspects with regard to what the government will do next. A clear position on the Drug Regulatory Authority is a case in point and directions with regard to other regulatory domains, where the government does not have institutional arrangements to begin with are equally important.
In sum, therefore, a health policy must evolve in the context of the structure of Pakistan’s federation and constitutional stipulations. It must clearly signal policy positions with regard to the core, but difficult issues related to the federal government’s role in health with clarity and state how the Ministry of Health will transform its own capacity to cope with these issues. Operational details of relevance to service delivery must be left to the provinces. However, relegating responsibility to the provinces is not a guarantee of success especially if the current institutional capacity of the provinces and districts does not transform, both from a performance-effectiveness as well as transparency perspectives—Pakistan’s health policy woes will, therefore, unfortunately, not come to an end with pronouncement of the national health policy 2010.
The writer is the founder and president of the NGO think tank, Heartfile. E mail: firstname.lastname@example.org