Governance Issues

It was highly recommended by the bureaucrats and technocrats that political interference should be minimized as this leads to nepotism and favoritism at every level and is affecting the overall governance in the country. There should be respect for the law and merit. Every decision should be made more transparent and everyone should be accountable. The stakeholders and the public should be given an opportunity to participate in decision making. Some of the politicians also suggested that there should be bureaucratic reforms. The patronage culture should also be dealt with by introducing strict laws to ensure merit and accountability.

A senior technocrat suggested “We should have respect for law, merit, accountability at every level and transparency”. (Key Informant, 8)

A health ministry official suggested “We should do things on transparent. All the world campaigns have transparency behind their success. Only with transparency, we can assure that we are going right. The worst thing with our governance is transparency. We need to come up with some credible people”. (Key Informant, 1)

Another health ministry official suggested “It will be very difficult, but right people should be placed at the right places. Secondly, it is very important to reduce bureaucracy and political influence. Accountability is needed because most unqualified people are sitting there and doing nothing”. (Key Informant, 26)

A retired bureaucrat suggested “The government should be held accountable and responsible for its decisions”. (Key Informant, 37)

5.7.6 Devolution

The technocrats recommended that there should be more devolution at the local level and the communities should be empowered to take their decisions. The local authorities should be made more financially independent as they

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know the grass root problems well. There should be capacity building at the provincial level to handle devolution.

A senior health ministry official suggested about devolution “More and more devolution. Give responsibilities to the people”. (Key Informant, 28)

A national level politician suggested “You need to devolve power. The local people should have the resources and responsibilities to solve their issues”. (Key Informant, 11)

5.8 Conclusion

This chapter depicted a clear and comprehensive picture of the complex policy environment and role of the key policy players in the fragmented Pakistani health systems. Policy process in general was perceived to be top- down, non-participatory, rushed, secretive and highly bureaucratic. It was the prerogative of a few policy elites who made the policies behind the closed doors. They were seen as having captured the policy making/implementation process. Health policy trajectory clearly revealed incoherent and disconnected national health policies. The June 2011 Devolution created more confusion as far as the role of policy actors was concerned.

The factors behind the implementation gaps as seen by the policy actors were: corruption, political interference, nepotism, institutional flaws, wrong priorities, capacity issues, lack of merit and accountability, lack of evidence- based health policies, financial constraints, overburdened tertiary care, absence of a proper career ladder for health professionals, limited decision space for district health officials, lack of capacity building, dual practice by the medics, maldistribution of health workforce, rent-seeking, lack of political attention, multiplicity of actors, donors’ agenda, lack of conducive working environment, brain drain, lack of inter-provincial co-ordination, patrimonialism, lack of national ownership of health, hidden alliances and policy-politics nexus.

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Some of the key informants were keen on discussing different political eras in the country’s history which gave a tour d’ horizon of the political history of Pakistan. The information provided clearly indicated that constant domination of the political power and the state apparatus by narrowly based elite seeking to advance its private and parochial interests lay at the heart of the problem. Regime changes either military or civilian did not make any substantive difference. Due to this, stasis in some of the state policies was seen. This was due to the some strong policy players pursuing their own interests for authority and resources.

The same pattern was mirrored in the health policy subsystem where the key policy actors had strong coalitions as some of the informants referred to. It was either due to their political influence and institutional roles. Institutional position of the key players (politicians and bureaucrats) also identified where these actors were located in the complex political environment. Power, interests, patronage and incentives were the main underlying drivers. The excessive use of patronage in case by case policy making/ implementation to favour narrow interest groups has derailed decision making, its rules and transparency.

As far as the role of policy elites was concerned, majority saw the bureaucrats as the agenda-setters and having the non-decision making power in their hands. This group of actors could easily be termed as the Veto Players in the overall policy sphere. The apparent blame game by policy players had a strong underlying power nexus. This provides a strong foundation for the later chapter where all these findings will be discussed in light of the relevant theoretical frameworks.

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Chapter Six: Discussion

6.1 Introduction

This chapter draws together the main elements of this study as emerged from analysis of the data. The findings will be discussed and argued in light of the wider literature. The theoretical frameworks selected will be applied to the results. The main points of this chapter will inform the conclusion and recommendations.