The recent 18th constitutional amendment has brought about unprecedented changes in the devolution of executive and legislative power from the center to the provinces. By June 2011, the Health Ministry will stand abolished. What does this mean as far as public health is concerned? Is this a positive move or a step backwards? These are important questions in view of the fact that Pakistan’s public health record has been far from exemplary, as can be seen from the abysmal state of our hospitals, the recent doctors strike and our failure to comply with international health regulations in under-reporting the bird flu virus. Pakistan also runs the risk of being the only country in the world where polio has not been eradicated.
In her paper, Health and the 18th Amendment, Dr. Sania Nishtar observes that whereas devolution of several responsibilities in health is a step in the right direction, it is imperative to retain a federal or national role in health. In other words, the federal government should not completely devolve its health related powers and there should be some sort of supervisory institution at the federal level particularly in regard to a national health policy and medicine and drug regulation.
There are currently two proposed alternatives to a health ministry. One is to divide and fragment each of the areas covered by health and siphon them off into different existing ministries. For instance, the Finance Ministry can deal with international agreements on health; bodies such as the Pakistan Medical & Dental Council and the Health Services Academy can be lumped with the Planning Commission and drug regulation will be under the purview of the Ministry of Industries. The second alternative is to establish a Health Commission.
Dr. Nishtar feels that both these options are fundamentally flawed. Dividing up the portfolio of the health ministry between different existing ministries, “would be extremely deleterious since it would augment existing fragmentation of the health sector,” says Dr. Nishtar. “Additionally, placing drug regulation under the Ministry of Industries is fundamentally flawed as a policy move. The primary objective of a medicines policy is to make quality essential medicines affordable and accessible for all, as a priority. Any objective relevant to the business side of pharmaceuticals must be subservient to this core objective.”
Establishing a Health Commission is also an inappropriate alternative according to Dr. Nishtar. “Commissions are created for defined objectives and do not have a policymaking mandate. The construct of a commission and the needed institutional parameters are quite different from an ongoing policymaking and oversight role, which a ministry of health has to play to protect and promote the health and wellbeing of the country’s population.”
In the past, fragmentation of the health portfolio has created problems in policy making, sometimes suspending the entire process in limbo. Pakistan for instance, was the only country in the world where health and population were two separate ministries. This institutional separation was detrimental in areas such as family planning and reproductive health, which were divided between both ministries.
The Health Ministry itself was plagued with several weaknesses and there is no doubt that it needed a serious overhaul. Dr. Nishtar agrees that, “Although the ministry was theoretically tasked with many important roles, it lacked capacity to do full justice to them. Its functionaries were overwhelmed by administrative and logistic tasks, which related to day-to-day administrative control and micromanagement of the national public health programs and attached and subordinate institutions.” An institutional inertia, familiar to many government institutions had also crept in as a result of which the ministry continued to perform sub-optimally.
However, despite its many weaknesses and mainly ineffectual past performance, the Ministry of Health plays an important role in many areas which need to be served nationally at the federal level. For instance, the responsibility for health policy has been almost completely devolved to the provinces, “a bit of misnomer when one considers that a ‘health policy’ in the traditional context denotes an official statement by the highest level of government, usually the cabinet, which sets the mission, vision, goals and strategies, and in many cases, operational plans to achieve health and health systems outcomes,” comments Dr. Nishtar.
A national health policy can still be placed before the Council of Common Interests (which has certainly assumed greater importance post-the 18th amendment), however, some provinces do not concur with the notion, and want to exercise their prerogative to pronounce their own policies. Dr. Nishtar stresses that, “A set of values and principles needs to be articulated at the national level—the provinces should endorse them as unifying threads in relation to the state’s commitment to health…standards should also be prescribed where inter-provincial conformity is needed and in other areas where national policy coordination can obviate unnecessary duplication.”
There are other health related matters that have a truly national character where overall responsibility must be retained at the federal level. These include health information, disease security, compliance with international regulations, trade in health, certain aspects of human resources and the regulation of medicines and related products. Most federating countries have similar functions retained at the national level. For instance, medicines and drugs are almost always regulated centrally, usually by a ministry or a semi-autonomous public regulatory authority, such as the Food & Drug Administration in the United States (where health is not even a federal subject). Other notable examples include, Germany and Switzerland. Even countries such as India where some (but not all) aspects of drug regulation were previously decentralized, are now moving towards centralized regulatory arrangements.
“The move to decentralize drug regulation in Pakistan would, therefore, be a unique experience, in contrast with internationally prevailing trends. Pakistan would become the first country in the world to devolve drug regulation,” says Dr. Nishtar who is concerned that devolving drug regulation would also entail unnecessary duplication. “Each of the four provinces will replicate work currently done by one organization in every other country of the world. This would have resource implications in the current fiscally constrained environment. Capacity constraints at the institutional level also have to be considered.”
Dr. Nishtar has analysed this aspect of devolution very thoroughly in her paper. She says that a plausible way forward would be to replace the Drug Control Office with an independent drug regulatory agency. “Extensive spadework has been done in the last ten years to plan and strategize such transformation… however, progress was stalled due to change in government.” If appropriately structured, Dr. Nishtar says that a Drug Regulatory Authority can overcome existing capacity and resource constraints.
However, proponents of the idea of scrapping the Ministry of Health argue that all its functions can be carried out at the provincial level. Dr. Nishtar feels that these notions are mistaken. Firstly, the costs of doing so would be exorbitant. In fact, the argument of fiscal managers, which centered on using the ministry’s abolition as a way of curtailing expenses would be self-defeating if the costs of creating parallel provincial structures is borne to bear. Secondly, there would be enormous capacity constraints making it impossible to carry out these functions at the provincial level. The Ministry of Health struggled unsuccessfully for ten years in trying to institutionalize a National Health Policy Unit despite massive donor support. Imagine trying to do that in each of the four provinces! It would be an institutional nightmare and fiscally, out of the question. Thirdly, it is instructive to draw from the experience of other countries with federating structures. Most have a ministry of health or equivalent institutions i.e. state departments which have clear and meaningful missions whilst corresponding institutions at the sub-national level have the ‘health service delivery mandate.
Dr. Nistar says, “There are many other areas where central coordination by the Ministry of Health on behalf of the provinces, even in the scenario of enhanced provincial autonomy, can spare provinces from unnecessary duplicative work for which they neither have human resource capacity nor the institutional arrangements in place. This consideration is of particular relevance to provinces with weak capacity. Federal oversight—its weaknesses notwithstanding—ensured the delivery of some services which will be risked in the event of loss of that role.”
Ideally, the Ministry of Health should not be abolished, says Dr. Nishtar, as it is also symbolic of the significance of health at the national level. However, given that its abolition is symbolic of provincial autonomy and the massive devolutionary reforms brought about by the 18th amendment, such a hope is unlikely.
In her paper, Dr. Nishtar advises that the ministry of health be recast as a Division. “In addition to being the option with a constitutional color, it is also in keeping with the spirit of times vis-à-vis provincial empowerment and devolution of powers. Converting a ‘Ministry’ into a ‘Division’ would mean stepping down hierarchically in the federal government’s organogram and therefore, indicative of its intent to relinquish powers. However, at the same time, it will enable retaining a coherent institutional structure at the federal level to serve national functions in health in a consolidated manner, without the kind of fragmentation feared in the currently envisaged options.”
Since a Division has to be placed under a ministry, Dr. Nishtar points out that this would also be an opportunity to develop appropriate inter-sectoral linkages for health, which have been the missing piece in health sector planning and development. A health division could be placed under the Ministry for Planning, or, a new a Ministry of Human Development could be created, which could be given the responsibility for health, education, capacity building, labor and overseas Pakistanis. Another option would be to create a Ministry of Inter-Provincial Coordination and place the health division under that.
All in all, it is imperative to retain a high-level federal institutional structure to develop a national vision for health and serve national health-related objectives. Whether this takes the form of a Division within a ministry or some other arrangement, it is vital to have in place. In any event, the transition of powers from the center to the provinces must take place incrementally and smoothly and it is perhaps advisable that in the short to medium term, some sort of interim arrangement is established until the counterpart structures in the provinces are fully established and functional.
