assessing the impact of devolution on healthcare and education in pakistan prepared for pakistan devolution support project united states agency for international development contract no. dfd-i-00-05-00129-00, order no. 01 prepared by ritu nayyar-stone robert ebel sonia ignatova khalid rashid with harry hatry george peterson the urban institute 2100 m street, nw washington, dc 20037 1 (202) 833-7200 www.urban.org february 2006 ui project 07862-001 assessment report pakistan devolution support project table of contents i. introduction .................................................................................................................................................... 2 i.a the background of devolution ................................................................................................................. 2 i.b the structure of government ................................................................................................................... 2 ii. progress and challenges to effective democratic devolution............................................. 8 ii.a effective and cost-efficient service delivery............................................................................................ 8 ii.a.1 health......................................................................................................................................... 8 ii.a.2 education ................................................................................................................................. 17 ii.a.3 water supply and sewerage.................................................................................................... 22 ii.b local fiscal roles and responsibilities ................................................................................................. 28 ii.c accountability and citizen participation.................................................................................................. 38 ii.c.1 upward reporting and accountability ........................................................................................... 38 ii.c.2 citizen participation ...................................................................................................................... 43 iii. key findings and conclusions ................................................................................................................ 46 iv. recommendations ........................................................................................................................................ 49 annex a: list of organizations and individuals met in the field annex b: bibliography list of figures, tables, and boxes figure 1. the three tiers of local government figure 2. administrative structure of districts figure 3. administrative structure of the tehsil municipal administration figure 4. intergovernmental relations in the health sector figure 5. intergovernmental flow of funds in pakistan table 1. key indicators for pakistan’s disparate federation table 2. number of districts and tehsils/talukas, 2004 table 3. selected responsibilities of districts, tehsils/talukas, and unions table 4. budget estimates of the health department, thatta district table 5. structure of district health facilities table 6. salary and non-salary expenditures on education, 2004–2005, rs. millions table 7. management structure of education department table 8. government schools lacking basic facilities, kohat, nwfp, 2005 table 9. provincial grants to tmas table 10. expenditures and revenues associated with water table 11. approval steps for the development of infrastructure in a tma table 12. direct spending responsibility: conceptual assignment of public expenditures vs. pakistani practice table 13. tax assignment for district, tehsil, and union governments table 14. country comparison of subnational own-source revenue generation table 15. types of data collected for hmis and emis table 16. composition and election of the monitoring committees table 17. roles and responsibilities of the monitoring committees table 18. distribution of registered ccbs in the city district of karachi box 1. why districts matter box 2. vertical programs by the federal government box 3. guidelines for assigning expenditure functions to different levels of pakistani governments list of abbreviations adb asian development bank ajk azad jammu and kashmir bhu basic health unit bps basic pay scale ccb citizen community board dco district coordination officer dfid department for international development (uk) dg district government dhq district headquarters hospital dtce devolution trust for community empowerment dtw districts