Fiscal Devolution across Primary Healthcare Facilities

The Need

The fiscal devolution was a means to solve issues that existed at different levels of the health department of Khyber Pakhtunkhwa (KPK)

Central-level issues

1- Lack of investment in maintenance and repair of existing facilities

Investment were channeled through development budgets into new schemes instead of repair and rehabilitating existing healthcare facilities. ~15% of planned cost1 for reform allocated

2- Existing model to repair and rehabilitate inefficient

C&W was the only mechanism to provide infra upgrades and they have well-documented issues with their contracting.

District-level issues

1- Low planning capacity of DHO Office

DHO office responsible to plan and allocate expenditure to all health facilities with no capacity and capability to do so.

2- Delays in DHO-led procurement

DHO led procurement of essential equipment and medicines usually delayed (~3 months to a year) and inefficient to fulfill immediate facility level requirements.

Facility-level issues

1- Lack of essential human resource at facilities

Apart from permanent staff on department payroll, other staff had no leverage to get additional help such has security, helpers and cleaning.

2- Lack of facility capacity to communicate needs

DHO and facility communication weak due which was a result of lack of interest from facility staff and DHO capacity

The Need

The ground reality of the primary healthcare facilities in Khyber Pakhtunkhwa was a representation of these issues

Poor Infrastructure Outlook

Poor physical outlook of facilities with absence of necessary functionalities

700+ facilities damaged and never refurbished

Low Staff Presence

Irregular presence of staff (Medical Officers, Lady Health Visitors etc.)

MO Presence <50% across the province

Unavailability of Medicines and Equipment

Low availability of essential medicines and critical equipment

Medicine availability at 39% and Equipment availability at 77%

Lack of oversight

Poor management and oversight provided by district officials

No district routines set and no district oversight over facilities

The Solution

Fiscal devolution accelerated fund utilization via efficient fund allocation, release and execution

Non-devolved method led by Construction and Works (C&W) department
The Implementation

The devolution plan had to be supplemented with implementation support at different levels

Implementation Level

Central-level Implementation

Key Steps and Requirements

  1. Approval of devolution through management committees requires cabinet approval and political influence to expedite the process.
  2. Drafting and approval of laws and guidelines informing implementation.

Team Support

  1. Assist in the drafting of guidelines and laws.
  2. Engage with stakeholders for required approvals.

District-level Implementation

  1. District level leadership support required to understand implementation steps under devolution and its benefits.
  2. Agreement to engage facility staff to lead work on-ground.
  1. Train district officials on implementation steps.
  2. Assist in facility-level engagement and performance management.

Facility-level Implementation

  1. Creation of PCMCs and nomination of focal persons leading the committees.
  2. Opening of bank accounts for fund transfer.
  3. Scoping of work required, funds needed, communication to district-level, receiving funds and work initiation adhering to guidelines set centrally.
  1. Train facility level staff around guidelines and scoping of work.
  2. Establish performance management routines.
  3. Design data systems to track work progress and fund utilization.
The Impact

Within two years fiscal devolution led to remarkable impact

Better planning and execution

Higher transparency and accountability

Acceleration of project implementation

Increase in public trust in government

  1. Fund utilization based on needs identified by people operating health facilities offering a sharper understanding of spend.
  2. Work conducted at a substantially lower cost.
  1. Ability to track spending per facility and districts offering transparency in spend.
  2. Performance management routines established giving better oversight to health department on funds utilized.
  1. Devolution enabled high quality repair across 700+ facilities in 21 districts in KPK in a span of two years.
  2. Increased medicine and equipment availability throughout province due to faster procurement.
  1. Facilities made more responsive to the needs of the community leading to improved citizen outcomes.
  2. Repaired and equipped facilities led to higher patient load and higher quality service delivery.
The Impact

The scale of impact achieved through devolution was witnessed across the province

Rural Health Centre in Lakki Marwat
Basic Health Unit Bathroom in Karak
Patient Service Area at a Basic Health Unit in Abbottabad
Basic Health Unit Bathroom in Haripur
Facility exterior of Basic Health Unit in Kohat
MO Room of a Civil Dispensary in Peshawar