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Pakistan and a national health vision


September 12 2016

Pakistan has finally come out with the National Health Vision (NHV) after a hiatus of several years following the challenges of devolution. In its 69 years, Pakistan’s national steering response has been historically slow, having produced only four national health policy documents of which only one went all the way with parliamentary endorsement.

Set aside the delay in coming up with a national steering document, the NHV of 2016-2025 does have a distinctive flavour. While previous policy documents were embedded with ambitious targets, often prescriptive and largely disease-focused, the vision document provides a sector-wide strategic direction and a strong resonance on governance, but intentionally stops short of providing recipes and targets, which are left for contextualisation and consultation with the provinces.

Overarching values are transformation and change, equity, and resilience and accountability. These are translated into key policy directions, such as better use of existing funds, investing funds for social protection, performance accountability of government services, joint production of key targets with the private sector, regulation, producing human resources for rural health markets, and standardised, quality services beginning with the primary health sector.

Of note here is that the development of the NHV has been an unusual, albeit welcome, process. National documents are typically developed in the federal capital, often hurried through, with tokenistic consultations — all of these are non-starters in the current devolutionary context. First, necessitated by devolution, the NHV roundtable consultations were hosted in turn by each of the provinces and AJK. Second, the consultations involved a predominance of Pakistani resource entities across government and private sectors rather than just the usual suspects — from Shaukat Khanum to Pims, from Pakistan Medical Association to PMDC and Hib Council, from the Drug Regulatory Authority to pharma, IBA to Balochistan University, civil society, government entities and more. Third, the federal ministry played its cards well in taking provincial political stakeholders on board, and having a stable team to deliver on the process.

Pakistan has the funds, does it have the will?

While the NHV has finally been developed, there is little cause for complacency. Pakistan has a history of producing policy documents that are rarely implemented. The greatest challenge will be federal-provincial dynamics, which has suffered since devolution from many unresolved issues resulting in the abrupt transfer of power. The NHV provides a strategic direction for provinces to form their own policies and action plans. The federal ministry can only coordinate this process and hold back its hand from vertically implementing the NHV.

Moreover, five years into devolution, a common inter-provincial and federal forum for health has yet to be established. Such a forum is needed to respond to common health issues, routinely share progress, and also share best practices and expertise. The federal ministry has not responded to fill this vacuum and has tended to contact provinces only when it has a burning issue to implement — such as international pressure to eradicate polio, or the prime minister’s cabinet’s vertically-led health insurance scheme.

Second, necessary capacity to translate and implement the NHV is required in both the federal and provincial ministries. The national ministry is still organised in its pre-devolution structure of federally led vertical programmes, is thin in terms of staff, and lacks dedicated strategic, policy and information units to coordinate effectively. KP and Punjab have moved to restructure their departments to an extent; Sindh and Balochistan are yet to begin building the necessary capacity for stewardship. Aside from the federal ministry, which has a stable top- and mid-level leadership, all provinces have had constant transfers in health bureaucracy that prevents any vision, let alone an action plan, from taking off.

Third, all the ministers’ attentions at the launch of the NHV were on international donors to fund their vision. But Pakistan is not Liberia or Somalia. It has funds to invest in health – the priority to spend in human development needs to be set by the government – and existing government health funds need to be stretched to do much more. Waste, inefficiency and poor planning choices made with existing funds need to be tackled.

More and more, it’s the international partners that are substituting the government’s role for spending in essentials such as vaccines for immunisation, contraceptives, etc. Instead, Pakistan needs to ask its development partners for technical assistance in implementing the NHV — from producing quality and affordable local drugs, to regulation of health services, to health planning for healthy districts and cities, etc.

Pakistan, after many years at least, has a common national menu for its neglected health sector — do Islamabad and the provinces have the willingness to rise above party lines for the common good of the invisible Pakistani citizen?

Originally published by Dawn Pakistan 

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