A senior health advisor commented, “Of course there are barriers in the implementation but I think mainly it is driven by political motivations and resources as these are always limited”. (Key Informant, 23)
A senior health ministry official at the national level said, “Ah implementation
is primarily at provincial or district level .For one policy if its national policy it’s different but in provinces it’s more local priority. It could start for not taking stakeholders in confidence and then non-realistic targets. Not linking the policies with the financial resources and then the capacity of the health system, so a weak health system could also be a barrier”. (Key Informant, 13)
Financial constraints, political motives, fragmented health systems and lack of involvement of key stakeholders is being stressed in the above quotes.
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A technocrat said, “It is evident who started polio eradication? Is that a Pakistani agenda? There is WHO agenda”. (Key Informant, 18)
It is evident that in a complex policy environment, international donors and their agendas directly influenced the success or failure of policies. Surprisingly the donors were blamed by just one group of the participants, which were mainly the technocrats, and not by the politicians or bureaucrats.
Lack of resources, absenteeism and lack of rural health workforce were considered other impediments. A bureaucrat at the centre commented:
“Lack of resources becomes a barrier. Just to quote an example. I would take the example of health. Provision of health to the rural population is our responsibility. We have scarcity of doctors working in our rural areas because of so many reasons and they are not willing to serve there. With the imposition on the ban on the recruitment, we cannot hire new doctors. Health facilities, which are not attended by doctors, become an impediment for the smooth implementation of the policies for example if we do not have the money in my office we would be stuck up. So lack of resources would become an issue”. (Key Informant, 17)
Levels of implementation
Technocrats at the senior level were quite keen to share the policy implementation process. They told that the implementation was mainly at three levels, micro, macro and meso level. Meso level was the middle level where all cogs and wheels were located. Then the policy was passed onto the implementers. The real issue was at the meso level where the finances are involved. The financial constraints have always been a big issue. This is the point where many policies got stuck, remained partially implemented and eventually fizzled out.
5.3.2 Devolution
The 18th amendment and Devolution of health [June 2011] (which is described in detail in chapter two) was one of the most common themes that
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emerged in the interviews. Some of the politicians who belonged to the Pakistan People’s Party (PPP) which designed the 18th amendment, saw it as a necessary shift to a more federal system, but most of the national level bureaucrats were concerned about the ability of provincial governments to assume regulatory authority in these areas which are often labelled as the capacity issues by the participants. Capacity was mentioned at the provincial level by almost all the participants,
Majority of the bureaucrats at the federal level were of the view that the provinces were still dependent on the centre for the support as they were so used to it. One of the provincial level bureaucrat mentioned that the financial control was still with the centre and it caused difficulties in efficient delivery of the services. One politician shared that there was a lot of resistance from the centralists on the pretext that the then government was trying to create four nations by giving more share to the larger provinces and this would aggravate the sense of deprivation in the smaller provinces.
Those who were against it saw the whole process of devolution suffering from a knee jerk reaction of the provincial governments who were unprepared, incapacitated and unaware of the implications. Regarding capacity issues of the provinces, the provincial level technocrats and bureaucrats had varied views. Some said the provinces like Punjab and Sind handled devolution better than others did. Many belonging to Khyber Pakhtunkhwa (KPK) suggested that their province was doing better.
A national level politician criticized devolution and saw as if it never happened and was badly needed if Pakistan was to survive. One provincial level politician viewed it as a political decision under political pressures.
One of the politician remarked, “It was an ill planned and hasty decision”. (Key Informant, 11)
One of the senior personnel in the health ministry said “After the passage of 18th amendment health [June 2011] was devolved to the provinces and the work has become difficult and challenging. So you can say that we are
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currently in the transition phase, trying to recover from the devolution of health which was not conducted in an orderly and planned manner and we have to face a number of unnecessary challenges.” (Key Informant, 3)
A national level politician who brought in the 18th amendment remarked, “It was not a political move rather it was the need of the hour”. (Key Informant, 2)
A technocrat remarked, “The people who are fond of centralization often throw this argument that provinces are not ready, but I say, “Unless you jump you cannot swim”. (Key Informant, 33)
Some of the technocrats at a senior level were of the view that the devolved system of governance was necessary. It was delayed by 67 years and over the past 60-70 years; there was an accumulated frustration in the provinces. A minority of the participants were quite keen on sharing the background of the 18th amendment and told in detail about the federal and concurrent legislative lists (described in detail in chapter two).
One of the bureaucrats (KI, 30) explained in detail that Pakistan is a federal state and provinces are expected to be more autonomous. Regulatory mechanisms need to be uniform across the provinces, but the power rests with the federal government. Anything which is not in the federal legislative list is a provincial prerogative. Actually, in 1956 there were 3 legislative lists, two federal and one concurrent list (explained in the background). The 1973 constitution said that one would be federal and the other concurrent. The 18th amendment has done with that concurrent list. They abolished 21 ministries. There should not be any education or health minister at the center.
A head of an International organization (KI, 7) praised the decision. She was of the view that before devolution the district managers were bypassed and they were just a post office. She tried to convey that after devolution the managers should take the ownership and plan according to the needs of the population and now the onus should be on them to plan and prepare. But it was a minority view.
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Findings revealed that devolution instead of making things clearer created more confusion among the policy makers and implementers. A devolved subject like health had a ministry at the federal level. The donors seemed to be confused as well as was evident from the informants who were heading some donor organizations.
It was evident that there was no political will on the part of governments to improve governance. Every successive government had her own priorities. Most of the participants saw no accountability or transparency in the whole system of governance in Pakistan and perceived it to be one of the major challenges as well and mother of all evils.
Corruption was mentioned by all the participants and was seen to be the greatest governance challenge in our setting. Decision makers thought it unnecessary to involve the public. The elected representatives who were the parliamentarians were not sensitized to their real problems. Politicians favored their own people in all ministries and Sifarish was norm of the day (Sifarish is a commonly used in the Pakistani society, mainly by the influential to favor someone not on merit).
One of the participants remarked “In Pakistan there is no culture of justification. They don’t think they are responsible to the public”. (Key Informant, 3)