The initial euphoria marking devolution has receded, clearing the way for an analysis of the losses and gains accruing from a decision that was generally hailed in the interest of provincial autonomy.
One year on, it has become evident that the devolution of the Ministry of Health has fragmented health. What did devolution do to health? To begin with, it made Pakistan the only federal country in the world without a federal health institution. Despite its many weaknesses, the pre-18th Amendment Ministry of Health played an important role in numerous areas that should have been retained at the federal level, as practiced in most federating countries. Rather than establishing a re-cast federal structure for health to serve key national functions, all departments that were previously functioning under the umbrella of the Ministry of Health are now lying helter skelter under various ministries, divisions and departments.
The task of national planning and coordination (with provinces and international development partners) has been assigned to the Planning and Development Division. The Economic Affairs Division is handling dealings and agreements with other countries and international organizations in the fields of health, drug, and medical facilities abroad, as well as scholarships and training courses in health from international agencies such as WHO and Unicef.
Responsibilities related to international aspects of medical facilities and public health; international health regulations; port health; and health and medical facilities abroad have been assigned to the National Regulations and Services Division, which is also handling national associations in medical and allied fields such as the Red Crescent Society and TB Association. Institutions such as Pakistan Medical and Dental Council, Pakistan Nursing Council, College of Physicians and Surgeons, National Council for Tibb, Pharmacy Council of Pakistan, Drug Regulatory Agency of Pakistan, and Directorate of Central Health Establishment-Karachi have all been placed under the National Regulations and Services Division.
Similarly, the Directorate of Malaria Control has been placed under the Inter-Provincial Coordination Division while the National Health Information Resource Centre has been merged with the National Institute of Health and the Tobacco Control Cell with the Health Services Academy. Vital health statistics has been placed under the Federal Bureau of Statistics.
While some medical institutions have been devolved, the Cabinet Division has assumed administrative control of others. Medical and health services for federal government employees, as well as the administrative control of some of national institutes, have been placed under the Capital Administration and Development Division. The States and Frontier Region Division has been tasked with coordinating medical arrangements and health delivery systems for Afghan refugees.
Other health domains that have been devolved include several vertical health programmes, lunacy and mental deficiency, and prevention of the extension from one province to another, of infectious and contagious diseases. Legislation pertaining to drugs and medicines are a joint responsibility of the drug regulatory agency and the National Regulations and Services Division. Moving on to medical, nursing, dental, pharmaceutical, paramedical and allied subjects, education norms have been devolved except to the extent of federal areas. However, educational facilities for backward areas and for foreign nationals, with some exceptions fall under the IPC Division.
Reflecting on the sorry state of affairs while talking to ‘’The News’ here Monday, Dr. Sania Nishtar, an internationally acclaimed health professional heading the NGO Heartfile said, “Fragmentation is detrimental. Fragmenting information and disjoining it from planning and policy simply means that the government is undermining its own mandate and decision-making ability in health.”
It is pertinent to recall that in May 2011, Heartfile published a report titled ‘18th Amendment: retaining national roles in devolution.’ The report offered valuable and timely insight about national roles in health, offering strong justifications for retaining this national role. It identified four national subjects in health namely, health information, inclusive of research in health; health regulation; international commitments; and national health policy, with respect to federal mandates in health, overarching norms, norms of care, inter-sectoral action, trade in health, health technology and disaster response. “It is also a national responsibility to ensure policy coordination, and support provinces with weak capacity,” it pointed out.
The report pointed out: “despite extensive changes by the 18th Amendment, the Constitution still provides space for national functions and a federal role in health.” On the matter of the abolition of the Ministry of Health, it stated: “the proposition of abolishing the Ministry of Health is not a matter defined in the 18th Amendment but interpretation of the same Amendment. The Constitution did not at any time-before or after the 18th Amendment-include health per se, as a specific legislative subject. A federal institutional structure to serve national health responsibilities and within that context, reform of the Ministry of Health to make it compatible with devolution is an imperative.”
The report recommended the establishment of a Health Division as the preferred option. It proposed that unlike the Ministry of Health, which was never structured properly for national functions, and as a consequence, never had the full range of capacities, the new federal structure should have adequate capacity.
In the report, Dr. Sania also published an analysis which looked at the five options with respect to the way forward-i) status quo, i.e., the Ministry of Health stays as it is; ii) abolishing the Ministry of Health and giving its functions to other federal entities; iii) creation of a Health Commission; iv) retaining the Ministry of Health as such, but scaling back is role; or v) recasting the Ministry and scaling it down as a Health Division. A summary evaluation of each option was given using nine evaluation criteria. Unfortunately, the cut-and-chop formula that scored the lowest was selected by the government as the preferred option. Before the ill-effects of this fragmentation reach a point of no return, it is time steps are instituted to rectify the post-devolution chaos in health. Dr. Sania informed that a WHO mission is currently in town to take stock of existing problems. It is hoped that mission will take stock of the problem of fragmentation.