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There are new reports of casualties in Pakistan but not from terrorism. Instead, some 150 poor patients died after receiving contaminated drugs from a public cardiology pharmacy in Lahore because the country’s politicians abolished the federal health ministry without creating an appropriate national drug regulatory agency, as explained in a recent Lancet article by Dr. Sania Nishtar. The failure was not only predictable but predicted. Before Pakistan devolved health sector responsibilities to the country’s provinces, many people raised concerns over the fate of key national programs related to disease surveillance, drug regulation, and medical supervision (including a blog that I posted a year ago). Unfortunately, this latest news shows that the critics were right to be concerned.

This is only the most extreme case that I’ve seen in which decentralization has debilitated public health functions. Many Latin American countries also decentralized public health services in the 1990s only to find that immunization rates fell or surveillance data was compromised. Most have recovered from these shocks to the health system, reestablishing key functions at the national level and devolving others. But the tendency to think that all health sector services are the same and can be devolved to subnational authorities – whether they involve assuring the quality of drugs, epidemiological surveillance, health financing regulations or managing health clinics – is astonishing. The diseases and injuries that result when these functions are neglected are often invisible to the public. This time, in Pakistan, they are only too visible. Hopefully, federal and provincial officials will take this as a wakeup call to establish, fund, and support the creation of an effective federal drug regulatory agency as well as to address the other health sector responsibilities that are best suited to national action.

The devolution of Pakistan’s health care services to the provincial level is not necessarily bad. In an earlier article, Dr. Nishtar argued that this strategy could work if federal officials were given authority to focus on public health functions that benefit from centralization while other services are devolved. But in this case, central functions are paralyzed by power struggles between regional and national authorities, and citizens are paying the price with their lives.