dr talib lashari national conference mdgs: improving maternal health in pakistan margalla hotel,...
TRANSCRIPT
Dr Talib LashariNational Conference
MDGs: Improving Maternal Health in Pakistan
Margalla Hotel, IslamabadNovember 25-26, 2013
3 Years Since DevolutionStock Taking: Implications
for MNCH
Overview• Introduction• Devolution: Cabinet Div, CCI, Federal Legislative
List• Implementing Devolution Reforms• Vertical Programs – status • MDGs targets• MNCH: Inequities • Challenges• Conclusion• Recommendations
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Introduction
• Constitution (Eighteenth Amendment) Act 2010: paradigm shift
• Momentous change: health services placed closer to communities.
• Implementation has been challenging -preparedness at relevant levels
• Clarity regarding the roles and responsibilities :federal and provincial tier.
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Introduction
• Cabinet Division notification of June 29, 2011: eight different Divisions assigned residual functions
• Planning Commission/P&D assigned the prime role of “national planning & coordination in the field of health”
• Recently, Ministry of National Health Services, Regulation and Coordination (NHSRC) established
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Cabinet Division NotificationsDate Notification December 2, 2010; April 5, 2011; and June 29, 2011:
Devolution of 17 federal ministries to provinces. Devolved ministries also include Ministry of Population Welfare; and Ministry of Health.
December 15, 2010 Adjustment of employees of the devolved ministries/divisions to other ministries
March 31, 2011 Establishment of CADD
July 29, 2011 New ministries/divisions i.e. National Harmony; Human Resource Development; Professional and Technical Training
October 26, 2011 Four new Ministries along with Divisions i.e. National Heritage and Integration; Disaster Management; National Regulation and Services; Food Security and Research
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Decisions of Council of Common Interest
• Council of Common Interest (CCI) held April 28, 2011 considered a summary submitted by the Finance Division. The CCI decided that the Federal Government shall provide funding for the vertical programs in Health
• The vertical programs in Health will receive funding at the level of 2010-11 budgeted level
• CCI also decided: The financing for development program of Population Welfare beyond June 2011 would depend upon the approval of ECNEC for this program. Later on the PC 1 of the Population program was approved.
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Federal Legislative List Federal Legislative List Part I Part II
Fourth Schedule, Article 70 (4).Legislative Lists Federal Legislative List
Entry 3. International affairs; the implementing of treaties and agreements, including educational and cultural pacts and agreements with other countries
Entry 11. Legal, medical and other professions.
Part I: Entry 19. Port quarantine, seamen’s and marine hospitals and hospitals connected with port quarantine.
Entry 32. International treaties, conventions and agreements and international arbitration
Entry 17. Inquiries and statistics for the purpose of any of the matters in this Part.
Part I: Entry 57. Inquiries and statistics for the purposes of any of the matters in this Part.
Entry 7: National Planning & national economic coordination including planning and coordination of scientific and technological research.
Entry 13. Inter-provincial matters and coordination
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Implementing Devolution Reforms
•Tactical vs. Strategic Issues•Planning Commission: Resolution of outstanding tactical issues being faced by provinces•July 2011-June 2012: resolving tactical issues
• Devolution issues were also being discussed at i.e. IPC; High Powered Committee of the Cabinet; Devolution Cell at the Cabinet Division etc
Concerns of Donor •Pre devolution mechanisms need to be translated at provincial level•Equality in donor support Concerns of Provinces • releases of funds• Level of funding• Future of vertical programs• donor grants• Lack of flexibility in utilization• Resource gap • drug regulation• Procurement
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Devolution Reforms
Inter Provincial Meetings• Inter-provincial meeting
January, 2012:– Current status and financing
modalities for vertical health programs .
– Provincial PC 1s at the fixed ceiling for PSDP FY 2010-11 as per decision of CCI
– March, April, 2012 the matters related to Project Management Units (PMUs) with regard to Global Fund and GAVI discussed.
– Mechanism of CCM– 3 PMUs shall function with a
revised structure till currency of available GF grant
• February 24, 2012 on PC1s; sustainability of programs; liabilities; release of funds and PMUs: – pending releases – DFID component for MNCH– level of funding same with
>salaries of LHWs
• Tactical issues resolved/Strategic• Policy coordination• Implementation of above
mentioned decisions require a coordination mechanism at federal and provincial level
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Status of Vertical ProgramsProgram Post Devolution
StatusStatus of Donor Grant Remarks
Maternal, Neonatal Child Health
Devolved to provinces
DFID Grant streamlined, disbursed, MoU extended till March 2014 on no cost basis
No PMU existing at federal level
National Program of FP & PHC (LHW)
Devolved to provinces
No Donor Grant No PMU exists at federal level
Expanded Program on Immunization (EPI)
Devolved to provinces (Polio Cell, EPI cell?)
GAVI support for vaccine procurement and Health Systems Strengthening (HSS) available
GAVI agreed to have a PC 1 for HSS to coordinate for systems strengthening to enhance immunization coverageNo PMU at federal level. Provinces implementing EPI programs
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MGDs 4&5 Economic Survey s; PHDS 1990;2007; 2012-13;MDGs Report 2010; PSLM 2004-05
Indicators 1990 2000 Current MDGs
Human Development Index
- - 146 (Low H D)
Infant Mortality Rate
102 77 74 (NN 55; <5:89)
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Maternal Mortality Ratio
533 350 276 140
Contraceptive Prevalence Rate (%)
11.8 28 35.4 55
Skilled Birth Attendants Coverage (%)
18.8 19 52 >90
Immunization (%)
51 77 53 (measles 61.4)
>9011
Challenges • Policy, Planning;
Governance – Post devolution strategic
issues– Coordinated policy
framework based on provincial policies
– Oversight, stewardship, evaluation
– Donor coordination – Flow of information and
surveillance– International
commitments
• Programmatic – Resource gap: federal,
provincial, donor funding
– Need assessment by donor/NGOs based on PC 1
– MNCH program: weak public private partnership; linkages with PWD, LHWs; communication strategy
– Releases, coordination 16
Conclusion
• Devolution has positive implications for MNCH; strategic & governance issues need to be addressed: which may affect gains
• Federal roles to be streamlined: Ministry of National Health Services, Regulation & Coordination (NHSRC)
• Federal, provincial, donor, INGOs/NGOs coordination for financing, procurement is weak
• Inequities hampering the achievement of MDGs
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Recommendations • Policy, Planning & Governance
– NHSRC may focus on broader policy coordination, TA, facilitation, stewardship, inter provincial & donor coordination, international commitments (should not engage itself in project approach)
– Coordinated Health Policy Framework• Health Systems Strengthening Unit
– Donor Coordination Strategy – Flow of information, IHR, vaccine procurement
• Programmatic – Federal, provincial & donor/INGOs, NGOs funding – gaps to fill
in – Integration of programs– Targeted voucher schemes, alternative financing & poverty
reduction initiatives (BISP) to address inequities in short to medium term
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