Yes. Pakistan is planning to abolish its Health Ministry in July.
When I first heard this news, I couldn’t believe it. Alarm bells went off in my head. What about disease surveillance? Who will enforce drug quality regulations? What does this mean for polio eradication? Is bioterrorism something that provinces can handle? Is it possible for a country with limited human resources to split public health policy across four or more different administrations?
Upon further inquiry, I heard a number of reasons for abolishing the health ministry – all of which were related to concerns over the most effective way of delivering health care services. The main argument I heard was that health care services would be more effectively managed and delivered by provincial governments that are closer to and more responsive to their citizens. I won’t go into the extensive debate over decentralized health care delivery because my primary concern right now is: what happens to public health functions related to regulation, supervision, information, and standards?
So, I was particularly pleased to hear the level voice of reason from Dr. Sania Nishtar who raised these issues in an opinion piece last December. She is currently seeking feedback on a thoroughly researched draft paper that recognizes the possible benefits of transferring the day-to-day management of hospitals and health facilities to provinces, while proposing a practical way to make sure that critical public health functions continue to be carried out at the federal level.
Dr. Nishtar takes the devolution of health services to provinces as an opportunity that would allow the federal government to extricate itself from managing a large dispersed workforce and focus its attention, instead, on roles that are clearly national in scope – roles associated with health information and disease security, drug regulation, and healthcare quality assurance. Her paper shows how this federal role has a legal basis even if other health functions are transferred to the provinces.
Pakistan should heed her advice. Other countries have derailed their national health functions during a process of broad political decentralization. As just one example, immunization coverage in Colombia fell after its reforms in the early 1990s; subsequently, the country responded by reestablishing a national level role in monitoring and assuring high coverage rates. Pakistan cannot do without a national level agency that focuses on public health broadly, undertaking such activities as disease surveillance, drug quality enforcement, and health promotion (e.g. reducing tobacco use and improving road safety). Pakistanis need it for their health.
And this isn’t just an issue for Pakistan. Viruses and bacteria don’t carry passports and don’t apply for visas. Pakistan is one of the last countries in the world with polio. Newly emerging infectious diseases can arise anywhere. The Centers for Disease Control in Atlanta needs a counterpart in Islamabad, just as it needs its counterparts in Geneva, Cairo, and Manila.
If Pakistan proceeds with its plans to abolish the federal Ministry of Health without providing for key national-level functions to continue and be strengthened, it will be making a big mistake for its citizens and for the rest of us. Hopefully, cool heads will take up Dr. Nishtar’s reasonable proposal. If they do, public health in Pakistan could actually come out strengthened. The Ministry of Health could be reborn as an agency focused on oversight, standard setting, regulation, and public health promotion – free of the responsibility for direct curative treatment. But time is short. I hope cool heads prevail.