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Abstract
Objectives Despite certain reforms undertaken in Pakistan to reorient its health system, the health-related millennium goals lagged behind many neighbouring and regional countries. This study was conducted to understand the implications of government reforms including the devolution on the National Maternal Newborn and Child Health (MNCH) programme; and to determine donors’ and development partners’ current and prospective role in the post-reform scenario.
Setting The donor agencies based in the federal capital Islamabad, as well as the federal and provincial government offices involved in the financing, design, oversight and implementation of various MNCH initiatives in Pakistan, were included in the sample.
Participants A descriptive qualitative study based on individual in-depth interviews with representatives from donor agencies and government offices (8 each) involved in programmes directly related to the MNCH sector.
Results The reforms are denounced as deficient in terms of detailed planning and operationalisation of the vertical programmes including that for MNCH. The government had to face coordination challenges with the provinces, which has affected donor engagement and funding mechanisms to a great deal. Investment in MNCH, population and nutrition has been the topmost priority of development partners in Pakistan. Their contributions towards health systems also include assistance in developing and implementing provincial health sector strategies, establishment of Health Sector Reform Units and investments in service delivery, research and advocacy.
Conclusions Any health sector reform must be complemented by a roll-out strategy, including robust support to the provincial health systems and to their capacity building. Development partners must align and coordinate their strategies with provinces to stabilise the MNCH programme in Pakistan. More coordination between the different tiers of the government and the donors could streamline MNCH partnership in post-reform times.
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Strengths and limitations of the study
Involvement of key officials from the federal government and international donor community in Islamabad enriched this study.
Use of qualitative methods provided deep insights vis-à-vis donors’ perceptions on the implications of health sector reforms.
Only those officials actively involved in Maternal Newborn and Child Health (MNCH) programming were chosen from the government and development sector.
Having used grounded theory and restricting the study universe to the MNCH programme, the findings may not be generalisable.
Limited resources and time constraints did not allow covering of the viewpoints of all provincial stakeholders.
Introduction
While there is good progress on reducing Maternal Mortality Ratios (MMR) and under-5 mortality rates globally, maternal and under-5 deaths have decreased negligibly in Pakistan,1 alluding to the need for a critical review of the national programme for maternal, newborn and child health. The world, in general, is unlikely to achieve the millennium target of a two-thirds reduction in child mortality, even though under-5 mortality declined by 47% between 1990 and 2012.2 Likewise, the rate of decline is less than half of what is required to achieve the MDG-5 (Millennium Development Goal) target of a three-quarters reduction in MMR between 1990 and 2015.1 Although there is immense focus on measuring progress to attain MDG-4 and MDG-5, the least discussed goal is MDG-8, which aims at addressing the development needs of developing countries with the support from the developed world. The quality and range of Maternal, Newborn and Child Health (MNCH) services in Pakistan are dependent not only on the allocations for health in the country's gross domestic product (GDP), but also on the contributions from development partners. Opposing the recommendation of WHO to allocate at least 5% of GDP on health, the Government of Pakistan has historically spent around 0.5% of its GDP on health.3 The contribution of the development partners accounts for 4.93% of the total health expenditure in Pakistan.4 Therefore, it is imperative to enhance the donor contributions for strengthening of healthcare services in rural and urban populations in the country. This being said, there is evidence that similar levels of health investment by donors can lead to better health outcomes in other countries.5
A key challenge in providing the MNCH services is the coverage gap between rich and poor in middle-income and low-income countries including Pakistan; a gap that, if covered, would save the lives of more than 700 000 women in 5 years.6 Despite certain reforms to reorient the health system, undertaken by successive governments of Pakistan, the progress of health-related MDGs has been too slow as compared to those of many regional countries having the same cultural, economic and geographic dynamics. According to World Health Statistics, under-5 mortality rate in neighbouring countries such as Iran (18/1000 live births) and India (56/1000 live births) is much lower as compared to Pakistan (86/1000 live births).1 Barely half the births are assisted by a skilled provider, and only one-quarter of married women of reproductive age use modern contraceptives.1 Pakistan, with its history of political instability, a dwindling economy, complex security issues and natural disasters, has somehow neglected the social sector, including health. Pakistan's investment in the social sector is among the lowest in the world, with <2% of total government expenditure going to health.7 Insufficient basic health services, inefficient staff, and inadequate medical supplies and equipment, are only a few direct causes of maternal and child mortality in Pakistan.8 These inadequacies are primarily linked with the meagre investment made in the government healthcare system.
The National Programme for Family Planning and Primary Health Care (Lady Health Worker, LHW) and the National MNCH programme, in spite of their achievements, reflect poor governance, weak linkages and integration between institutions, and poor management capacity, owing to the implications of 18th constitutional amendment, which has transferred the planning, financing and management of health sector to the provinces.9 ,10 At the same time, this devolution of powers from the federal centre to the provinces has provided an opportunity to the provinces to develop their respective health sector strategies according to their needs, resources and capacities. Health sector strategies were hitherto developed and in the process of implementation in four provinces of Pakistan.11 One of the key implications of the 18th amendment are the financial increments for the health and social sector in each province under National Finance Commission (NFC) awards.12 This opportunity, with amplified financial benefits to the provincial health sector, solicits the case for the generation of a broader financing mechanism to attain the universal coverage for MNCH care. Nevertheless, available finances are not sufficient to meet the needs of a rapidly growing population. Realising this need, the leading development partners are playing a complementary role in instituting health reforms in Pakistan. Donor support for developing the health sector strategies of the provinces and the commitment to roll them out are key initiatives.13 ,14 The constitutional reforms in Pakistan have also impacted the interaction of development partners at federal level, resulting in multiple window operations with provinces. However, the reinstatement of the Ministry for National Health Services, Regulation and Coordination (NHSRC) in the centre could be meaningful in supporting a one window operation with development partners, while also harmonising the provincial health sector strategies.10 Nevertheless, donors have pledged to continue their assistance to the federal government in some of the major MNCH initiatives until 2016.
The objectives of this research were twofold—to explore donor's perceptions regarding the implications of the constitutional reforms on the National MNCH programme, and to determine their current and prospective role as well as position in strengthening the MNCH programme in post-reform times in Pakistan. This study could therefore help development partners, provincial stakeholders and national policymakers to produce realistic, coordinated and well-concerted MNCH plans and programmes in the wake of a new political context.
Methodology
Study site
The study was conducted in Islamabad and the provincial capitals over a period of 3 months—May–July 2014. Purposive inclusion of the federal government and international donor community in Islamabad enriched this study to determine the role of development partners in MNCH programming as well as the implications of the constitutional reforms.
Study design and data collection
A descriptive qualitative study was conducted, using a semistructured in-depth interview guide, with the people holding key positions in the federal and provincial government, and international donor community (programme specialists). A one-on-one in-depth interview was the best method to employ for several reasons: (1) all the respondents were senior officials in their respective departments/organisations; (2) it was not practical to gather them all at one place for a group discussion; (3) the composition of the group of respondents would not have been homogenous, homogeneity being a pre-requisite for qualitative research and (4) as compared to a structured close-ended questionnaire, an open qualitative enquiry furnished more detailed insights and responses. The interview guide was prepared with the help of a literature review (see online supplementary file). Purposive sampling was carried out along with snowball sampling to reach out to the maximum number of respondents associated with the MNCH sector. We continued the data collection until no new information was emerging out of discussions and ideas were considered saturated. An in-depth interview guide included: open-ended questions on the contributions of development partners in addressing MNCH issues and setting priorities; coordination with key stakeholders such as the public, private and non-government organisation (NGO) sector; selection criteria and processes for healthcare financing in a province; and implications of recent reforms on coordination of development partners with the Government of Pakistan. After an informal rapport-building conversation, a one-on-one in-depth interview spanned over 45–60 min. All interviews were conducted and recorded, and transcribed, and later analysed by the principal researcher, who is a medical doctor and public health graduate. No refusals were encountered for conducting and either recording, or taking notes of, the interview.
Study participants
The study included participants from development partners and government representatives overseeing MNCH programmes in Pakistan. Donors funding MNCH programmes in Pakistan and likewise the public sector public health managers involved in managing the MNCH programme at the provincial level were included. Development partners assisting health sector projects other than MNCH programmes were excluded from the study. Respondents were briefed about the goals and objectives of the research as well as the researcher's background. Sixteen interviews were conducted, eight from development partners and eight from federal and provincial governments involved in MNCH programming and management. In-depth interviews were conducted after obtaining formal written consent. The interviews were conducted at the work place of the participants and there were no refusals. Table 1 presents details of methods employed for the study.
Study participants and methods of data collection
Data analysis
The principal researcher carried out the entire data management and analysis. Verbatim notes were taken and interviews recorded, where allowed, by the respondents. All data collected were transcribed and analysis was carried out manually by thematic content analysis. Specific nodes were developed for the questions and probes in the interview guide. Significant findings and responses were aggregated as subnodes and later analysed to develop themes. Information from literature and responses of representatives from the government sector and development partners were then triangulated in the Discussion section.
Confidentiality, anonymity and privacy of the data were assured to the respondents of the interview.
Results
Results are presented in themes emerging sequentially from our study.
Implications of the constitutional reforms
Study participants are of the view that the constitutional reforms were somewhat abrupt and deficient in terms of detailed roll-out plans. The sudden abolishment of the Federal Ministry of Health created a lacunae for the funding and operationalisation of these vertical programmes, among which the most affected were the National Programme for MNCH, and the LHW programme. Interim technical assistance and a swift transfer of the administrative and financial resources were not facilitated by the central government, which affected the smooth functioning of these vertical programmes. However, they did acknowledge that establishment of the Ministry of NHSRC and, later, a pro-active involvement of the Planning Commission, were meaningful to address certain impediments in operationalisation and financial support to these vertical programmes. Findings also suggest that development partners also faced the challenges of coordination with the Government of Pakistan to deliberate on current and prospective MNCH projects after the devolution.We were quite confused, as if has happened suddenly. We knew the process of reforms was going on, yet we were not prepared. (Government representative, Sindh)
Overall contribution by the donor agencies is of enormous level. But after the 18th amendment, things were quite unclear and uncertain for a certain period of time. And it affected by and large the programming, the operations, and yes the beneficiaries suffered too. (Development partner-4, Islamabad)
Contribution of development partners towards the MNCH programme
All respondents highlighted the contributions from the development sector to identify and address various MNCH issues. Some of the key contributions include the technical assistance and financial support to complete the Pakistan Demographic Health Survey 2013 (PDHS), the development of 5-year health sector strategies for the provinces, establishment and strengthening of the supply chain management plan to bridge demand–supply gap of Family Planning products, and research development to advocate for cost-effective interventions and strategies for MNCH care. Investment in MNCH, population and nutrition programmes has been the topmost priority of the development partners in Pakistan.We give financial aid to government of Pakistan for MNCH. Our contribution is about 50%. We also give technical assistance. There is a direct support to MNCH, and an indirect one to the LHW Programme. (Development partner-1, Islamabad)
Donors provide funding, capacity building, technical support to conduct national survey and supplies for health facilities and family planning. (Government representative-12, Islamabad)
We all know that MNCH indicators are poor in Pakistan. Malnutrition is more prevalent in rural Pakistan. Our country health strategy is to invest in MNCH and nutrition. (Development partner-4, Islamabad).
Alignment of donor strategies with national priorities
Respondents from the development sector (multilateral and bilateral partners) stated that rolling out of the provincial health sector strategies is an opportune time to invest in MNCH. Multilateral development partners mentioned the need for an integrated PC-1 (Planning Commission form) that has been approved in the Punjab and Khyber Pakhtunkhwa provinces. Integrated programmes include MNCH, population and nutrition, which have important prospects for the development partners to enhance the performance of the provincial health departments. Moreover, harmonisation of the interprovincial health sector strategies and plans are equally important and should not be overlooked.Our common country programme is aligned with national development priorities reflected in the Pakistan framework for economic growth and in the new One United Nations Programme. (Development partner-2, Islamabad)
Ministry of NHSRC and inter-provincial coordination have important role to play so that donors’ investment and the provincial policies are aligned towards a common goal. (Government representative, Balochistan)
Nutrition, MNCH and population are integrated in KPK and Punjab. This integration will be meaningful to facilitate one window operations with donors. (Government representative, KPK).
Coordination of development partners with governments and NGOs
The development partners fully recognise that their contribution to the MNCH will be more effective in leveraging wider resources to support the Government of Pakistan to develop policies, legislation and budgets that work in congruence. Development partners regularly coordinate with the federal/provincial governments NGOs proactively through various forums such as the project steering committees and technical working groups, donor coordination platforms and donor conferences. These coordination mechanisms were affected for some time due to reforms. However, the Planning Commission Pakistan, Economic Affairs Division and now the Ministry of NHSRC, all played a pivotal role in addressing the communication gap between the development partners and vertical programmes. At the provincial level, Health Sector Reform Units/Programmes are playing an imperative role to facilitate coordination. The development partners claim that they also communicate with each other effectively to avoid duplication of MNCH programming in Pakistan.We are involved in a number of partnerships in the area of young child survival and development with key stakeholders such as public private and NGO sector in Pakistan. (Development partner-2, Islamabad)
Government usually has review meetings, interactive sessions, consultative meetings and field visits where we have engagement of NGOs, private sector and development partner's collaboration so that we should all be on the same page. (Government representative, Punjab)
After the constitutional reforms (18th amendment), the role of coordination and planning was assigned to the Planning Commission. There was issue of devolved vertical programmes, financing of vertical programmes and problems with regulation and coordination. Commission did a fairly decent job of overcoming all the teething problems. (Government representative, Islamabad).
Criteria for choosing a province or programme area
The development partners chose a province or a specific programme area as per the government health sector priorities and the common country programme document (CCPD). The CCPD of Pakistan for 2013–2017 prioritises maternal health to ensure that Pakistan can accelerate progress towards meeting its MDG targets. Findings also suggest that the government seeks support from development partners in the areas where its own technical and financial capability is weak and the coverage is minimal. Establishment of Health Sector Reform Units and development of health sector strategies have provided a coherent direction for development partners to invest in MNCH.The basic criteria for choosing a province or a thematic area for resource allocation to province are based on the needs highlighted by the government and it is reflected in the common country programme document and federal and provincial annual work plans. (Development partner-6, Islamabad)
Basically, if the government's own footprint is weak, then we always look towards the NGOs, international development partners and donors for assistance. (Government representative, Gilgit Baltistan).
Effect of devolution on development partners’ scope, role and position
The current role, scope of work and position of the development partners in the wake of constitutional reforms has linked them more with the provincial governments. Development partners consider ‘devolved reforms’ an opportunity to coordinate with provinces on MNCH-related subjects. According to the respondents from the development sector, an increased control of resources at the provincial level without detailed roll-out planning and a weak capacity of provincial health managers may slow down MNCH programming in Pakistan.Initially in pre devolution period, we were targeting at the national level, so the national level capacity was being enhanced; but that was not trickled down to the provincial and district level. (Development partner-2, Islamabad)
We ought to expand the scope of work, now in line with 6 provincial governments. We are missing a federal counterpart. Devolution has been chaotic, as there was no clarification on donor engagement and funding mechanisms. (Development partner-7, Islamabad)
The capacity at provincial level needs to be enhanced after the devolution. That's a reality, and we should all educate ourselves. (Government representative, Balochistan)
The smaller provinces should be given more chance and exposure to interact with the donors. (Government representative, Gilgit Baltistan).
Discussion
There is concern about the transfer of powers and responsibilities to the provinces without planning, which created problems not only for provincial health managers, but also for development partners; hampering the donor engagement and funding mechanisms of the MNCH programme. Our findings are consistent with the published literature, which identifies similar issues of donor engagement with the vertical programmes as key implications of health sector reforms.15 Such reforms must consider mechanisms to be put in place for an effective coordination of development partners with the provincial governments. This becomes even more important because the Government of Pakistan is faced with the challenging task of formulating a new NFC Award in 2015.16 It is therefore pivotal to develop the provincial capacities on technical and financial management of health-related subjects including MNCH. Likewise, it would be equally important for the federal government to harmonise donor sector programmes and investments in each province, which by virtue of recent reforms have their own provincial health sector strategies. Although the reforms of 2011 were highly criticised, these offer many prospects to improve the MNCH scenario in Pakistan. Improving MNCH in Pakistan is a key priority of development partners as evident from a number of initiatives spread over two decades, including the assistance to formulate provincial health strategies.10 These strategies entail a series of goals that essentially would reconstruct the health system in Pakistan, with focus on availability and coverage of essential healthcare packages. Therefore, donors’ assistance to roll out health sector strategies cannot be understated. Our findings and the literature review suggest that bilateral and multilateral donors are now supporting the provincial governments to roll out health sector strategies.15 ,16 This research presents a case study to understand the importance of communication between the provincial governments and the development partners, and how the role of federal structures such as the Planning Commission and Ministry of NHSRC can bridge the gap. Thus, the federal structures also played a positive role in terms of directing the development partners not only to prioritise initiatives, to be aligned with the development plans of government, but also to develop programme and fiscal management capacity of the provincial health departments.
Constitutional reforms call for reviewing the scope, role and position of the development partners in MNCH programming in Pakistan. As provinces have developed health sector strategies after a thorough consultative process with the donors, academicians and researchers,17 a clear direction is set for the development partners to align their MNCH programming with the provincial health strategies. En route, the non-state actors, including donors and NGOs, can play a substantive role, through capacity building of the provincial and district managers for supporting in-service delivery, research and management. Development partners must get involved in carrying out more research and advocacy initiatives to support the public sector healthcare system.18 This phase of decentralisation ought to bring decision makers, service providers and the development partners closer, and make them more well informed and more accountable to the populations they serve.8 ,9 Integration of vertical programmes for MNCH, nutrition and population in the post-devolution phase will promote intersectoral coordination, which is deemed the cornerstone for revitalisation of primary healthcare services in Pakistan.
Conclusion
The development and operationalisation of the provincial health sectors’ costed strategies is a key achievement of the constitutional reforms in Pakistan. Here, the development partners ought to align their country strategies with the provincial health sector strategies. Increased control over health-related subjects at the provincial level calls for thinking about new solutions and providing more direct investments by the development partners in provincial health sectors. By being better aligned and more coordinated, and responding to the needs of the provincial health system, development partners and key donors in the health sector can become instrumental in ensuring a stable, well concerted and responsive improved state of affairs for the MNCH programme in Pakistan.
Acknowledgments
The authors acknowledge the facilitation and assistance provided by the Health Services Academy, Ministry of National Health Services Regulation and Coordination, to carry out field data collection. They are thankful to Mr Haider Fancy for the English language editing of the paper.
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
- Data supplement 1 - Online supplement
Footnotes
Twitter Follow Babar Shaikh at @babartshaikh
Contributors FP and BTS conceived the study design and instruments and, drafted the successive drafts of the paper. FP collected, cleaned and analysed the data. BTS supervised the data collection and helped in the analyses. AM conducted the critical review and added intellectual content to the paper. All the authors read and approved the final draft.
Funding The study received a small amount of funding for data collection as part of a postgraduate thesis, from the Health Services Academy.
Competing interests None declared.
Ethics approval Ethics approval for this study was granted by the Institutional Review Board of the Health Services Academy.
Provenance and peer review Not commissioned; externally peer reviewed.
Data sharing statement No additional data are available.