In a Comment published Online First by The Lancet, Pakistani public health experts announce their shock and dismay at the Pakistan Government's plans to abolish its ministry of health. The Comment is by Sania Nishtar, Heartfile, Islamabad, Pakistan, and Ahmed Bilal Mehboob Pakistan Institute of Legislative Development and Transparency, Islamabad, Pakistan. Publication of the Comment coincides with the publication of a report from Heartfile (a non-profit, non-governmental organization [NGO]) that provides an in-depth analysis into the proposed abolition and its implications.
The 18th constitutional amendment recently announced by the government has granted provinces greater autonomy, and has devolved decision making in many sectors including health. The authors say: "By June this year, Pakistan could be the first country without an institutional structure—a ministry, state department, directorate, or equivalent structure—at the federal level in charge of national responsibilities for health. This amendment comes at a time when there is a dire need to increase the capacity of the health system in view of many serious challenges. For example, the failure to eradicate poliomyelitis means that Pakistan might be the last remaining reservoir of endemic poliovirus transmission in the world."
The report being published alongside the Comment has, says Nishtar (also author of the report) attempted to underscore the salience of national health related functions in a federating state where health is a devolved subject. Key messages of the analysis centre on defining national roles and articulating their policy rationale. The constitutional rationale for retaining these roles in the post 18th Amendment situation has been analysed and, where impediments existed, solutions have been proposed to overcome constraints.
While the authors appreciate that devolution of power can have benefits, they add: "It is vital that national health matters are identified, and related responsibilities are entrusted to a federal institution."
They highlight the specific issue of drug regulation, saying: The move to devolve drug regulation when several countries are moving towards regional models of regulation is questionable. These problems create an imperative for increasing health system capacity, rather than abolishing the Ministry of Health. An appropriate federal agency can help by sparing provinces from duplicative work for which they neither have institutions nor resources."
The Ministry of Health should, say the authors, instead be reformed, since they note that it was "never structured properly for national functions and therefore did not have sufficient capacity."
Finally, they express their fears that other countries may follow Pakistan's example. They conclude: "Pakistan should not set a wrong precedent that could encourage federal units (provinces or states) in other countries to demand the abolition of a federal role in health. Future decisions should be guided by the overarching provisions in Pakistan's constitution that morally bind the state to reduce inequities in society."
Sania Nishtar, Heartfile, Islamabad, Pakistan. T) + 92 300 8540974 E) sania@heartfile.org
Journal
The Lancet