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
Approval of devolution through management committees requires cabinet approval and political influence to expedite the process.
Drafting and approval of laws and guidelines informing implementation.
Team Support
Assist in the drafting of guidelines and laws.
Engage with stakeholders for required approvals.
District-level Implementation
District level leadership support required to understand implementation steps under devolution and its benefits.
Agreement to engage facility staff to lead work on-ground.
Train district officials on implementation steps.
Assist in facility-level engagement and performance management.
Facility-level Implementation
Creation of PCMCs and nomination of focal persons leading the committees.
Opening of bank accounts for fund transfer.
Scoping of work required, funds needed, communication to district-level, receiving funds and work initiation adhering to guidelines set centrally.
Train facility level staff around guidelines and scoping of work.
Establish performance management routines.
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
Fund utilization based on needs identified by people operating health facilities offering a sharper understanding of spend.
Work conducted at a substantially lower cost.
Ability to track spending per facility and districts offering transparency in spend.
Performance management routines established giving better oversight to health department on funds utilized.
Devolution enabled high quality repair across 700+ facilities in 21 districts in KPK in a span of two years.
Increased medicine and equipmentavailability throughout province due to faster procurement.
Facilities made more responsive to the needs of the community leading to improved citizen outcomes.
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 LakkiMarwat
Basic Health Unit Bathroom in Karak
Patient Service Area at a Basic Health Unit in Abbottabad