Health sector reforms: Factors influencing the policy process for government initiatives in the Punjab (Pakistan) health sector 1993-2000

The health sector in the Punjab (Pakistan) suffers from many shortcomings and to combat these, successive governments undertook different reform interventions. The most critical of these took place during the period 1993-2000, when the Punjab government introduced seven reforms in rapid succession, with decentralisation as a strategy common to all. Substantial inputs were made, but some of these were abandoned, others forgotten and yet others remained. Nonetheless, like many countries, where few governments have initiated any planned evaluation of reform efforts, there is also no evidence of any study having been undertaken in the Punjab. This study aims to explore factors that influenced the policy process for the health sector reforms undertaken by the government and to draw lessons for contributing to ongoing and future initiatives. In preparing to achieve this aim, frameworks were developed for the health system and the policy process for health sector reform. This is a qualitative research study, which employs a case study approach. Four cases were selected for study and, based on a framework for analysing the policy process, data was collected using interviews, focus group discussions and document reviews. With the help of a tailor-made computer-assisted data processing system, the qualitative data was analysed and findings are presented as four single-case studies. The cross-case analysis led to generating discussion and developing a multiple-case study and identifying factors influencing the policy process for the Punjab health sector reforms. The study revealed that six factors principally influenced the policy process in terms of their origin, design and implementation. These are: (1) the absence of clearly defined principles and purposes; (2) the insufficient involvement of the stakeholders; (3) the lack of a holistic view of context, focusing on the health sector; (4) the shortcomings of the policy machine-, (5) the need for a proper implementation structure; and (6) the administrative fatigue of donors. Given these findings, there are certain implications for the Punjab health sector, particularly overhauling the policy machine, developing the capacity of policyrnakers for policy analysis, and broadening the stakeholders' base.