DEVOLUTION PLAN AND

HEALTH CARE IN PAKISTAN

CHALLENGES AND CONSTRAINTS

 VISION
• Health is a basic human right and must be
available and accessible in an affordable
framework to all. To this end, an integrated
approach to public health in the district will
combine preventive, promotive and curative
health at all levels. Reductions in demand of
curative care, would be translated into
improvements in its quality.
• Promoting good governance in health sector, by
meaningful and consistent emphasis on prompt,
equitable and professional services delivery, must
become a cardinal principle of the department.
Devolution, Decentralization,
Debundling
It is the transfer of authority, or
disposal of power in public
planning, management and
decision making from the national
level to sub- national levels or from
a higher to lower levels of
government.
Main Objective:
philosophical & ideological

Providing the means for community

participation and local self-reliance and
ensuring the accountability of
government officials to the population.
 DEVOLUTION OF POWERS IN
HEALTH DEPARTMENT
OBJECTIVES
• Empowerment of the people at the grass
root level.
• To make the District the dominant level of
decision making in health department.
• Improve the quantity and quality of health care
delivery to the people close to their door steps.
• Integrated approach to public health,
combining, preventive, promotive and curative
health at all levels.
RESPONSIBILITIES/ FUNCTIONS
AT THE DISTRICT LEVEL
•Prevent and Control Communicable
Diseases and Non Communicable Diseases.
• Food Sanitation.
• Maintain medical and health statistics
under HMIS.
• Reproductive Health.
• Health and Nutrition Education.
• Environmental and Occupational Health.
RESPONSIBILITIES/ FUNCTIONS
AT THE PROVINCIAL LEVEL
• Make Health Policy for the Province.
• Legislate on Provincial health Issues.
• Drugs control under the Drugs Control Act.
• Monitoring and Regulatory functions of
Medical and Para Medical institutions.
• Health Research and related Health
information gathering.
 RESOURCE/ASSETS DISTRIBUTION
FOR THE DISTRICT
• Type-A or B [DHQ Hospital] hospitals.

• Type-C [Tehsil HQ] hospitals.

• Type-D [Civil] Hospitals
• RHCs.
• BHUs.
• Sub Health Centres.
• MCH centres.
• Dispensaries.
• Districts will be encouraged to establish their own Nursing,
LHV and Paramedical Training Institutes in due course.
 PROGRESS SO FAR
• Posts in Directorate General of Health Services
have been re-designated
• Budgets according to the new requirements.
• All DHOs and ADHOs have been briefed by the
department twice on its approved Devolution plan.
• Briefing was held for both DHOs and DCs of all
districts by Health Department
• All DHOs have been instructed to work as a team
with the DCs at the district level
• All DHOs have been asked to develop lists of their
assets for distribution
ADMINISTRATIVE STRUCTURE:
DISTRICT

District Coordination Officer

EDO: Finance and Planning Health

Public Health
District Headquarters Hospitals
Basic Rural Health Centre
Mother & Child Health
Population Welfare
 FUNCTIONS OF
EXECUTIVE DISTRICT OFFICER
• Ensure that the business of the department
and offices placed under his administrative
control is carried out in accordance with the
relevant laws and rules.

• Co-ordinate and supervise the activities of the

relevant offices.

• Ensure efficient services delivery by

functionaries under his control.
DISTRICT HEALTH MANAGEMENT TEAM
What is the purpose of a DHMT ?
Develop a Team approach
Share and Exchange Views
Reduce the workload of the DHO
Optimize Utilization of the Human
Resources
Improve Cooperation and Collaboration
among stakeholders
How is a DHMT Constituted ?

     DHO
     Other District Managers
     Public Sector Health Care Providers
     Private Sector Health Care Providers
 Community or its elected leaders
 Role of DHMT
 Sharing of experiences and exchanging of
views & ideas.

 Taking responsibilities and improving

technical efficiency by supporting,
assisting.

 Improve cooperation and collaboration

with the Government and private health
related sectors.
 OUTCOMES
• Well-defined structures have been developed and
resources allocated.
• Meaningful partnerships at provincial, district,
tehsil and community level, through the
establishment of DHMT,THMT and citizen boards.
• Detailed mapping of resources and services need to
be developed.
• In planning and implementation of program a
right based and integrated approach needs to be
developed.
• Meaningful action and capacity building would be
required at all levels.
 HEALTH EXPENDITURE
SITUATION AT PRESENT
• Almost 100% is out-of pocket
• Includes formal and informal private sector

• Questionable quality of care

• Considerable expenditures on unnecessary and

inappropriate (sometimes unsafe) care

• Inequity in financing of care

• No regulation or standards on fee charged

• Reliable information not available

 ADVANTAGES OF DEVOLVED
SYSTEM IN HEALTH CARE
• Administrative and financial powers to
district authorities / local bodies
representative.

• Involvement in devising the programs

relevant to the local needs and priorities.

• Strategies and plans acceptable for the

community and matching to their socio
cultural and socio economic background.
• User willingness to pay for PHC in the
public sector services, if they receive
improved care.

• The districts can recover substantial costs

and can retain the incomes.

• Creating sense of ownership.

• Strengthening of FLCF, answering many

primary health problems like high IMR,
high MMR and morbidity and male
involvement.
 CRITERIA FOR ALLOCATING
DISTRICT BUDGETS
• Population Size

• Socio-economic Development

• Health Infrastructure

• Health Needs / Problems (BOD Estimation)

• Performance Evaluation based on

predetermined indicators
• Combination of Above
 CHALLENGES AND
CONSTRAINTS
• Political willingness of provincial and district
governments to work in the new system.
• Defining their administrative roles with
limits and jurisdiction.
• Distribution of financial powers between
Provincial and District representatives.
(dependency of districts on provinces for
how long?)
• Financial and administrative capacity of
the district government.
• Resentment against the status quo at the
provincial level and fear of loosing
authority.
• Lack of trust and losing the profit.
• Status of Public Service Commission,
Medical colleges and Tertiary hospitals.
 THE INTERNATIONAL
DEVELOPMENT TARGETS
1. A reduction by one half in the proportion
of people living in extreme poverty by 2015
2. Demonstrated progress towards gender
equality and the empowerment of women
by elimination gender disparity in primary
and secondary education by 2005
3. A reduction by two-thirds in the mortality
rates for infants and children under age 5
and reduction by three-fourths in maternal
mortality - all by 2015