PILDAT
An Analysis
April 2011
Health and the 18th Constitutional Amendment
P
akistan is a federation, with power shared between the federal government and four major federating units - the provinces. Up until the recently
promulgated 18th Amendment to the Constitution of Pakistan, the federal government enjoyed a legislative, and stemming from it, an executive
role in several sectors of state governance, which were concomitantly provincial responsibilities as well. Scale back of that role is one of the
major changes introduced by the 18th Amendment, with provincial autonomy and devolution of legislative and executive authority in many sectors,
including health, as a result. Within this context, this analysis has focused on outlining modalities of the game change in health introduced by the 18th
Amendment and their implications at the health systems level. This analysis draws on qualitative insights. Its specific objective is to present the
technical and constitutional rationale for retaining a national role in health.
The analysis recognizes the political and constitutional imperative of provincial autonomy in Pakistan's federating system, and is fully supportive of
devolving health. This notwithstanding, it is critical that national subjects in health are recognized and related responsibilities are entrusted to a federal
institution with a health mandate. The analysis is grounded in Constitutional provisions, which morally bind the state to reduce inequities in a society
and uphold re-distributive social justice. This is applicable in the present case, both in relation to reduction of health inequities and addressing inequities
in capacity, which exist at the provincial level and have implications for their ability to promote health and well being of populations.
Whilst supporting devolution of health related responsibilities, the analysis also flags several capacity building imperatives. First, the importance of
building institutional competencies to devolve responsibilities. There are many prerequisites of successful devolution: a strong central state, functioning
public sector and technical and managerial capacity within the system, being the most important. There are gaps at each of these levels in Pakistan.
Secondly, it is critical that the new federal structure mandated with national functions in health should ly appropriately structured, and resourced and
should have adequate capacity. Ministry of Health was never structured properly for national functions and as a consequence never had the full range of
capacities. In the third place, devolving functions to the provincial level must proceed in tandem with capacity building at several levels within the
provincial health administrative set up. Lastly, there is need for due attention to reform the local government system, where there have been many
uncertainties over the last decade. The latter is necessary to decentralize management to smaller management units, from the provincial to the district
level.
Changes in Health Department after 18th Constitutional Amendment
1.
Changes in Concurrent Legislative List
Following subjects relevant to Health were part of the concurrent list that are now being shifted to the Provinces.
About the Brief Analysis
This Analysis has been created from the
paper “Health and the 18th Constitutional
Amendment” authored by Ms. Sania Nishtar,
President, Heartfile. The objective of the
analysis is to assist Parliamentarians to
understand the context, objective and issues
relating to the topic and to take wellconsidered position on the subject. The Brief
is also intended to enhance awareness of the
Citizens and the Media.
.
Acknowledgment & Disclaimer
Produced by PILDAT under the project
Electoral and Parliamentary Process and
Civil Society in Pakistan, supported by the
United Nations Democracy Fund. Any
omission or error in the analysis is not
deliberate. The contents of this Brief do not
necessarily reflect the views of the United
Nations, the United Nations Democracy Fund
or its Advisory Board or PILDAT.
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Table 1: Subjects relating to Health in the Pre-18th Amendment Concurrent Legislative List
Entry 20
Drugs and medicines
Entry 21
Poisons and dangerous drugs
Entry 22
Prevention of the extension from one province to another, of infectious or contagious diseases or pests
affecting men, animals or plants
Entry 23
Mental illness and mental retardation, including places for the reception or treatment of the mentally
ill and mentally retarded
Entry 24
Environmental pollution and ecology
Entry 25
Population planning
Entry 26
Welfare of labour, conditions of labour, provident funds, employer’s liability and workmen’
compensation, health insurance including validity of pensions, old age pensions
Entry 43
Legal, medical and other professions
Entry 45
Inquiries and statistics for the purpose of any of the
matters in this List