The Gateway Paper--proposed health reforms in Pakistan--interface considerations.

The Gateway Paper recognizes three system interfaces as being critical to the delivery of healthcare within Pakistan. These include the federal/provincial interface, the provincial-district interface and the public-private interface. A number of gaps in each area have been highlighted. At the federal-provincial interface lack of provincial ownership of federal initiatives, gaps in provincial counterpart arrangements, ambiguities about federal and provincial roles and responsibilities, conflicts over sharing of resources and gaps in understanding provincial requirements and poor coordination have been articulated as core issues. It is envisaged that the development of a broad based mechanism to develop a consensus on national policy positions, incorporation of appropriate guidance from the provinces, giving provinces an active participatory role in decision-making, garnering their support and clearly demarcating roles and responsibilities will obviate some of these issues as would the institutionalization of a federal-provincial coordinating mechanism to review actions at both levels with regards to progress on meeting stipulating goals. At a district level poor governance, limited capacity within the system, lag in granting full district level financial and administrative autonomy, and lack of operational clarity in the rules of business have contributed to the challenge. This is compounded by inadvertent centralization of some functions within the district, which political and administrative decentralization has paradoxically created and impediments to harnessing the role of communities. The clear delineation of these issues provides a substrate, which need to be at the heart of strategic reform within the context of the recent devolution initiative. At the public-private interface the absence of locally established principles, legislative frameworks, policies and operational strategies have been contributing to the adhoc nature of public-private engagement within the country, which leads to skewed powered relationships and lack of clarity in combined models of governance. Within this context the Gateway Paper makes a strong case for developing a set of norms and ethical principles, developing legislative and policy frameworks, and specific guidelines to steer such relationships with careful attention to accountability and sustainability related parameters.