Cultivating champions: Strengthening health financing reform capacity in Pakistan

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Cultivating champions: Strengthening health financing reform capacity in Pakistan Koohi Goth Women's Hospital in Karachi, Pakistan. Credit: World Bank.

An estimated 4.4%—or 11 million Pakistanis—will experience impoverishment due to out-of-pocket spending for healthcare services in 2024. Substituting such expenditures by increasing government spending on health is crucial not just to reduce poverty, but to spur continued progress towards universal health coverage in Pakistan.

Yet, at a time when debt repayment burdens are ballooning across the Global South and macro-fiscal outlooks are unfavorable, increasing government spending on health is a complex challenge for countries like Pakistan. The options available in these circumstances tend to boil down to just two: (1) increasing health’s share of public expenditures, and (2) using public resources allocated to healthcare more efficiently, particularly through an increased emphasis on preventative and primary healthcare (PHC). But let us now ask the important follow-on questions: How are these two options supposed to be achieved? And, even more instrumentally, who will do it?

While policy dialogue at the top level can be instrumental for change, within government agencies, advocacy and policy advancement often depends on initiatives of middle-ranking officers. In the case of health financing reforms, what is needed is a well-capacitated health sector administrator who can combine public health and economic arguments during policy discussions, thereby creating the ground for senior officers to win changes in public budget allocations for health.

However, more than a decade after health sector devolution in Pakistan, provincial budget processes for health have remained dependent on historical inputs and are largely non-strategic. The lack of any specialized graduate programs in healthcare financing have led to limited availability of expertise. The conclusion: a critical link in the theory of change behind increasing public financing for health appears fractured in Pakistan, especially at the provincial level.

To help turn this around, the World Bank--supported by resources from the Global Financing Facility, ThinkWell Global, WHO, and GIZ--embarked on a journey to strengthen the health financing policy reform chain. This began with a series of intensive workshops in health financing fundamentals delivered to a targeted cohort of mid-level managers comprising of provincial health department officials, experts from finance, planning and development board from across the country. None of the health officials had prior health financing expertise despite their involvement in provincial health financing policymaking processes.

Over the course of 8 months, this cohort convened once each in Islamabad, Lahore, and Murree. The purpose was to develop an applied familiarity with the core functions of health financing and to create a cohort of champions capable of advocating for health budget reprioritization and more efficient health budget utilization as and when needed. 

Mid-level-managers-grapple-with-conceptual-solutions-to-localized-health-financing-challenges-during-a-workshop-in-July-2024 Mid-level managers grapple with conceptual solutions to localized health financing challenges during a workshop in July 2024. Credits: World Bank Pakistan

 

The Technical Capacity Building for Health Financing Reforms Series focused on what was most relevant and actionable in the context of Pakistan’s devolved health sector using identifiable examples from the participants’ own provincial budget books.

In our experience, this highly contextualized training worked to build real capacity and catalyze real policy change. During our most recent workshop in late-summer 2024, one participant from the Government of Sindh’s Planning and Development department made a connection they had not previously made. It became clear to this planning specialist through discussions with facilitators and peers during workshop sessions not just how but, crucial for inspiring sustained action, why budgetary function codes for health could be reclassified to create more tailored budget plans that actually ensure timely release of budgeted allocations and releases for primary healthcare. If and when deployed, this means more medical supplies procured at district level, more essential preventative and promotive health services delivered through the public sector, and ideally, ultimately fewer burdensome out-of-pocket health costs borne by the people.  

As government officers, the workshops have sensitized us to the cause of prioritizing primary health care in policy making,” noted Dr .Amber Mir, an administrative services official from the Government of Sindh. This sensitization was immediately useful, Dr. Amber and her team were able to adapt arguments and evidence used in hands-on exercises during the workshop to finalize a new policy framework for PHC-strengthening in Sindh. 

Image Participants use workshops sessions to better understand data sources for measuring Pakistan’s health financing performance. Credits: World Bank Pakistan.

 

Similarly, a Financial Management Specialist from the Government of Khyber Pakhtunkhwa, Mr. Asad Ullah, noted that “In these workshops we learnt a lot about strategic procurements, pooling of funds, financial analysis,” and through repeated workshop sessions, “...we learnt new ways to enhance revenue as well;” ways that are actually applicable in Pakistan’s uniquely devolved setup. Upon returning at the conclusion of the three-part course, Mr. Asad Ullah initiated a new project working specifically on revenue enhancement options in health in Khyber Pakhtunkhwa.

These are the seeds of connection that can start to make a real difference in health sector allocation— and eventually better performance from Pakistan’s health financing system. 


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