Policy · Strategy · Devolution
Devolution and the health sector: building provincial strategies that get used
Since the 18th Amendment, provinces lead health service delivery. What turns a provincial health sector strategy into a living document rather than a shelf report.
Avicenna Consulting International · · 2 min read
The 18th Constitutional Amendment (2010) moved responsibility for most health service delivery in Pakistan to the provinces. Provincial health sector strategies followed, many of them developed with donor support. Some are well owned and actively used. Others are reports that were launched, filed and rarely opened again.
What separates the two? In our experience, four features.
They are anchored in provincial evidence and priorities
A useful strategy starts from the province's own burden of disease, service gaps and equity concerns, and says clearly what will be prioritised and what will not. Copying a template from another province or a global framework produces a document everyone agrees with and nobody acts on.
They are costed and linked to the budget
A strategy without costing is a wish list. The strongest ones are translated into a medium-term budgetary framework so that every strategic objective has a funding line, and the annual operational plan and the budget tell the same story.
They have clear sequencing and ownership
Each objective needs a named lead, a timeline and a way to coordinate across departments, district teams and vertical programmes. Integration of vertical programmes, often discussed but hard to do, needs an honest option analysis of what can be merged, what should stay separate for now, and what it would cost either way.
They have a built-in review cycle
Contexts change. A mid-term review, with the authority to adjust targets and priorities, keeps the strategy relevant and gives decision-makers a regular reason to come back to it.
The federal role still matters
Devolution does not remove the need for national standards, coordination forums and a single voice on international commitments such as the International Health Regulations. The best provincial strategies are explicit about where they depend on federal functions and where they stand alone.
Provincial strategy development is one of the areas where ACI's team has the most experience, and the lesson is consistent: ownership and a link to the budget matter more than polish.
