Our analysis did not assess performance outcomes and its attribution to specific health reforms post devolution. In decentralised Pakistan, health became prioritised for increased government resources and achieved good budgetary use. However, allocation priorities were not effectively adjusted and there was little effort at targeting of inequities.
Major strides were made in terms of provincially contextualised sector-wide health planning and legislations, but implementation has been weakly steered. There has also been a feverish proliferation in governance measures to improve, professionalise and regulate healthcare delivery. Some have had wide roll-out, others have been only partially implemented and at times, even aborted. Global findings show that political decentralisation is associated with higher health expenditures and even higher in case of both political and fiscal decentralisation.
Decentralisation experiences in Kenya, 45 46 Nigeria 47 and Mexico 48 report weak mechanisms for resource management in subnational governments. There is scant evidence from developing economies on post devolution planning and governance; however, literature from Sweden and UK supports the case of improved regional planning and innovations post decentralisation. Our analysis shows that high political-bureaucratic ownership of health facilitated progress but weak stewardship skills and frequent leadership changes at subnational level, vulnerability to interference by local elites and feeble national coordination constrained effective implementation.
The federal—provincial relationship post devolution remained troublesome having a disadvantaged start with abrupt transitioning, unresolved resource sharing issues and ad hoc vertically led dialogue. There is scant literature on politics of health decentralisation in LMICs.
Chaotic interprovincial coordination is reported from West and Central African states, where the central government resisted relinquishing resources and attempted to re-empower the central government. We contend that examination of decentralisation should be expanded to include process assessments to detect challenges and help manage responses. We propose a few recommendations. First, investment for technical capability development in devolved structures is required early on as most decentralisation experiences in LMICs, driven by sweeping political process, will not provide time for a learning-by-doing incrementalist approach seen in technical driven experiments with decentralisation in OECD countries.
Second, technical support for the central level to shift to a new modus operandi should not be over-looked as part of capacity building efforts. Third, measures are needed for political management of decentralisation to safeguard against local political pressures, leadership stability, and continued centre-province discussion on issue interpretation and consensus building. Contributors SAZ framed and led the analysis and wrote the paper. MB and EVL contributed in framing the analysis, tools and editing the paper.
AR and NI collected and analysed data. DWO provided literature search. JBP reviewed and edited the paper. Disclaimer All views expressed here are those of the authors and do not represent the views of the Bill and Melinda Gates Foundation.
Forgot your log in details? Register a new account? Forgot your user name or password?
Search for this keyword. Advanced search. Latest content Archive Authors About. Log in via Institution. Email alerts. Article Text. Article menu. Health systems changes after decentralisation: progress, challenges and dynamics in Pakistan. Abstract Decentralisation is widely practised but its scrutiny tends to focus on structural and authority changes or outcomes.
Statistics from Altmetric. Devolution: extensive authority, abrupt process and partial recentralisation Pakistan population of million 14 is spread over four provinces—Punjab, Sindh, Khyber Pakhtunkhwa and Baluchistan—and a small portion resides in federally controlled territories. View this table: View inline View popup.
Several federal and state laws already allow patients to directly access obstetrical and gynecologic care without a referral, and that principle should be applied for all sexual and reproductive health services and providers in all jurisdictions. Serious reform will require broad consensus and a significant financial investment by federal and state governments, employers, households, and other stakeholders. Other sources of savings would likely arise from paying providers Medicare rates that are lower, on average, than private rates. It is time for Obama to let go with his pals and paybacks. However, it is important that potential out-of-pocket costs also be taken into consideration when defining affordability under a mandate.
Table 1 Distribution of federal—provincial roles and authority. Government spending on health Health spending post devolution depends largely on provincial contributions. Table 2 Health allocation and expenditure by provincial governments. Stewardship and planning In Pakistan, sector-wide planning was initiated for the first time after provincial devolution.
Table 3 Provincial planning and governance initiatives. Private sector harnessing Pakistan has a mixed health system for primary care comprising a large network of government health facilities, private individual practitioners, philanthropic organisations and private medical entities. Integrating vertical healthcare programs Pakistan has a long history of implementing vertical preventive health programmes, programmed by the federal ministry and co-financed by both federal and provincial ministries.
Leadership support, capacity and federal—provincial coordination Proliferation in health systems initiatives post devolution has been driven by strong support by provincial governments and the civil bureaucracy. References 1. Decentralization in health care: strategies and outcomes. Rethinking decentralization in developing countries.
World Bank Publications , Decentralization in developing countries. World Bank staff working paper , Levaggi R , Smith PC. Decentralization in health care: lessons from public economics. In : Health policy and economics: opportunities and challenges. Maidenhead : Open University Press , : — Bossert T. Analyzing the decentralization of health systems in developing countries: decision space, innovation and performance. Soc Sci Med ; 47 : — Decentralisation in Kenya: the governance of governors.
Vaughan S. J East Afr Stud ; 5 : — Arellano-Yanguas J.
Aggravating the resource curse: decentralisation, mining and conflict in Peru. J Dev Stud ; 47 : — OpenUrl CrossRef. Francis P , James R. World Development ; 31 : — Jommi C , Fattore G.
Regionalization and drugs cost-sharing in the Italian NHS. In : Euro observer. Pakistan Go. Overview of the constitution eighteenth Amendment act, , A health systems approach for strengthening primary health care services. National health vision Pakistan — , Statistics PBo.