A few weeks ago, a “naukri pesha mazdoor” named Asad Umar of PTI and ex-CEO of Engro shared an excellent article titled “Policy Brief: Health Systems Governance” through one of his tweets. Unfortunately, the author of the article is not identified – neither in Asad’s tweet nor in the article itself. It was a good read and made some excellent recommendations. For your reading pleasure, I have uploaded the document on the internet at the following link – Policy Brief: Health Systems Governance.

[Based on a discussion with Asad on Twitter, subsequent to the publishing of this article, he understands the policy brief to have been developed by an Islamabad based think tank by the name of Research and Development Solutions. Thank you for the update Asad!]

Photo Credit: Jump the Curve

I wanted to share my two cents (or is it two paisas when I am blogging from Pakistan) on the recommendations that the article made based on my experience of being part of several very large, enterprise-wide, business process re-engineering initiatives at Fortune 500 companies, involving change management as a pivotal part of the program.

But first, here are the key problems that the author of the article (if any reader knows of the author, please contact me so I can properly attribute the work to the rightful owner) identifies in the recently devolved Healthcare system of Pakistan. I am quoting them verbatim from the article.

• Despite the recent devolution, the overall planning, Human Resource Management and Fund Allocation still continue to be centralized, from Federal now at the provincial government with little autonomous decision making allowed for the districts that actually implement health programs.
• Nearly all programming is based on inputs (and some outputs), with little regard to health outcomes.
• The information flows within the health system are limited with little feedback to field level implementers about the nature or quality of their work.
• The current monitoring systems lacks the use of systematic evaluation and analysis of available data and the few evaluations that do occur are seldom incorporated into planning or monitoring processes or decision making.
• Funding for health is limited which further limits the productivity of health facilities and staff
• Corruption in the public health system is pervasive and perhaps among the highest worldwide and deeply undermines health outcomes and health sector performance
• Human Resource issues of non-merit based recruitment, deployment and promotion breeds inefficiencies, resentments and lack of morale
• Political Interference and Patronage limit any attempts at reform and add to all the problems discussed above

That’s a fairly comprehensive summary of the prevalent healthcare system issues post the devolution of the same to the provinces recently. Alongside these problems, a mere 0.6% of GDP being allocated to an already weak health sector of the country, requires an excellent governance model to effect any lasting positive change.

The policy brief takes a stab at a definition of good governance but I feel it lacks some key aspects of effective governance which are sprinkled all over the brief itself supported by a reference to a 2009 paper by Siddique et al. So I’d revise the definition of good governance to the following:

Good governance, in the context of politics and public administration, is an effective, efficient, participatory, equitable, transparent and accountable system of processes, policies and values to manage and maximize the economic, social and political objectives of all stakeholders of the governed ecosystem.

That’s a loaded, but comprehensive, definition in my opinion and perhaps I need a follow-up post to elucidate my thought process. Tackling it here will take me away from the subject matter of this article. I define it here though, because the policy brief does address each of the tenets of this definition in the proposed recommendations for effective governance of the health care system in a decentralized setting; it just leaves a tab bit missing in the definition itself.

So on to the proposed recommendations. Again I am copying below the salient recommendations made by the brief in their entirety:

• Further Decentralization of Planning to Districts along with Autonomy for Financial and Personnel Decisions 
• Incorporation of Systematic Evaluations including the use of existing program data into the overall Monitoring and Evaluation process 
• Performance Based Funding in the form of allowing facilities to retain the User Fees they collect 
• Increased Transparency and Control by electronic publication of government processes including HR, fund flows and Procurement 
• Citizen Participation using Citizen and Community Scorecards 
• Managing Human Resources based on a system of merit

You can read more details about these recommendations in the policy brief itself. I wholeheartedly agree with the proposal and just want to supplement it with some lessons learned from my professional experience.

Underestimating Resistance to Change: Executing and achieving lasting change in even a small organization, let alone a massive government ecosystem, is a huge challenge. In my experience, most large programs that introduce major changes fail miserably even if the change is for the broader good of everyone involved. Human beings, generally tend to be extremely pragmatic and resist any kind of change. Realizing this and being adequately prepared to tackle this resistance is an essential ingredient to successfully implementing the change program.

Lack of an Enabling Environment: A massive undertaking such as healthcare system reform requires careful development of an enabling environment in which the proposed changes can thrive and succeed. New legislative framework, revised institutional structure, strong leaders at all levels who can act as change agents for the program, adequate marketing of the program and its benefits to all stakeholders and developing an incentive structure that supports the change, are critical prerequisites to prepare the playing field for the game.

Lack of Participation by all Stakeholders: The policy brief adequately addresses this need post implementation of the program but it is equally important to involve all stakeholders – citizens/civil society advocates, private and public healthcare providers, district administration, etc in the planning process also. Participation in the design process of a large initiative does wonders to pave the path to acceptance of the program once rolled out.

Inadequate Leadership Support at all Levels: The execution risk of a large reform like the health care system revamp can be significantly reduced by having strong political support and ownership at the top level – federal and provincial – and by ensuring that strong leaders at local level are tasked with and empowered to execute the program. This may require inducting professional managers and technocrats at district level to spearhead the initiatives as strong change agents.

Poor Capacity Building: One of the most common reasons for failure of large programs is that sponsors fail to do adequate capacity building of the teams that will eventually be tasked with the operational management of the program. A classic example from my professional career is introduction of Enterprise Resource Planning systems without providing basic computer training to the field staff used to paper based processes and who at times do not even know how to switch on a computer. A substantial part of budget for successfully executed, large business process automation projects is typically reserved for capacity building of employees to ensure they can adjust to and maximize the benefits from the change.

Lack of Feedback and Continuous Re-factoring of the Program: Like software, no large reform program is perfectly designed. A successful program does not end with the rollout of the reforms in the last district. That’s just half the work done! A continuous stakeholder feedback collection, processing and re-factoring process needs to accompany the program to ensure that not only the initial teething issues are addressed and swiftly resolved, but on a long term basis, the program and its processes, policies, and systems can be continuously improved to maximize the expected benefits from it.

Role of Celebrating Success: I am amazed how many organizations who eventually succeed in rolling out large, enterprise-wide, change programs despite all the odds, fail to celebrate the success of their efforts! In my opinion, small celebrations and rewards to laud small and large victories alike serve as massive morale boosters and provide incentives to the stakeholders to continue to support the program until it becomes part of their DNA.

Kudos to the author(s) of the policy brief and I hope it’s picked up by the powers to be and steps are taken to make the devolved healthcare system in the country more effective.