by Dr. Sania Nishtar*
Pakistan suffers from many geo-strategic, macroeconomic, internal and human security threats. With many pressing governance concerns at hand, health reform may appear low on the list of priorities. That notion is misplaced for three reasons. Firstly, health reform is usually an elective process or a course, which is adopted by choice. However, at times it
is inadvertently forced on the system because of certain institutional changes that are made outside of it. Such changes in the functioning of the state have already been made in Pakistan and have altered the equation of responsibility in favor of the provinces vis-à-vis the federal government as far as health is concerned. The 18th Amendment to the constitution, the 2010 National Finance Commission (NFC) Award, ongoing reorganization of the devolution initiative have a deep bearing
on the executive’s functioning and the manner in which governance has to be reorganized in response to changes in structural norms. The 18th Amendment abolished the Concurrent List under which health was a subject in the purview of both the provinces as well as the federal government. The Local Government Ordinance 2001 stands omitted from the Sixth Schedule of the Constitution and therefore provinces have the prerogative to restructure the local government system according to
the mandate in Article 140-A. Under the 2010 NFC Award provinces also have additional fi scal resources to support plans. These changes in institutional prerogatives and responsibility have thrust drastic changes upon health governance. Indeed they can be the entry point into health reform with respect to reorganizing the stewardship capacity of state agencies—Ministry of Health and departments of health—which is an important element of any reform measure.
* Dr. Sania Nishtar is founder and president of the NGO think tank Heartfile.