Decentralisation’s Effects on Health: Theory and Evidence from Balochistan, Pakistan (Article)

The paper investigated the impact of decentralisation on health outcomes in Balochistan. It looked at how decentralisation has been [in]effective in improving (worsening) the overall healthcare services in the province. The impact of decentralisation was seen through the National Finance Commission’s (NFC) 7th NFC Award and the 18th Amendment to the Constitution. Both initiatives provide fiscal and administrative decentralisation to the provinces in Pakistan. Healthcare service in Pakistan is a provincial subject and any step that helps to improve the capacity of the provinces should supposedly translate into better services of healthcare. After the 7th NFC Award and the 18th Amendment, Balochistan has gained bigger fiscal space and provincial autonomy to improve social services including health. The study used a time series dataset from 1975 to 2020 from federal/provincial/district sources to provide micro-level evidence of static (or otherwise) outcomes in health corresponding to decentralisation. The paper compared the public health provision by provincial/subnational government with a centralised government to assess which tier is more effective (or otherwise) in health care provision considering various institutional types in both decentralised and decentralised regimes. The findings show that decentralisation did not improve health outcomes such as life expectancy, infant mortality rate, and child immunisation. Instead, it caused an increase in infant mortality in Balochistan. The paper concludes that health outcomes have not improved in post decentralisation despite bigger fiscal space and provincial autonomy. Thus, the province has not been able to increase healthcare services with qualitatively better outcomes.