Download Primary health care in Pakistan

Sylvia Sax, RN BSN MPH
Doctoral Student
Institute Public Health, University of Heidelberg
Pakistan: Country Profile
Area 796,096 sq Km











Multiethnic & linguistic diversity
4 provinces & 2 territories
Population ~ 145 million
History: Rich cultural heritage
+ natural & human resources
Productive agriculture sector
Strategic trade location
Per capita income: US$ 420-460
Literacy rate: 38.9%
Population doubling time: 25 years
Expenditure on health: 0.7% GNP
 70-80-% of health expenditure is on
human resources
Research
 Case Study of North West Frontier Province, Pakistan
(Khyber Pakhtoonkhwa)
 Health Services Quality
 Contextual factors that influence mechanisms for
quality improvement
 Qualitative and Quantitative methods
Nurses station in a
district hospital
Dust at base of tap
No soap
No hand towels
No guideline for
washing hands
No water
Key Health System Issues
 Critical shortage of health service providers




But not sure of the numbers (3 doctors/1 nurse)
External and internal brain drain (rural & donor)
Urban/rural discrepencies
Increasing reliance on paramedicals and ‚ward boys‘
 Weak regulatory framework


Limited registration of health facilities and providers with lack of regulatory
mechanisms
Professional groups weak influence on members
 Corruption


Political interference in transfers and postings
Private medical schools proliferating without transparent processes
The darker the red – the higher the corruption perception index
Ease of Corruption in the
Health Sector
 Uncertainty about what services should be
delivered and at what level of quality
 Involvement of private and public actors like
payers, providers, suppliers, consumers, and
regulators
 Asymmetric information among different actors
and their individual interests
 Extent to which private providers are entrusted
with important public roles
Adapted from Savedoff 2006
Corruption
The abuse of entrusted power for private gain
(Transparency International)
 according to rule- corruption where payments/bribe is paid to
receive preferential treatment for something that the bribe receiver
is required to do by law.
 Against the rule- where a bribe is paid to obtain services that the
bribe receiver is prohibited from providing.
 IMF and World Bank define corruption as misuse
or abuse of public force (office) for private gain
Sifarish
 In our research we consistently heard about the
practice of Sifarish (patronage, nepotism,
favouratism)
 Most interviewees identified Sifarish as a system,
with specific practices which are not described or
prescribed
 Those who reported on Sifarish usually described
harmful results of the practice
Culture and Corruption
Variations of levels of Corruption may be
due in part to variations in the social
norms and preferences that have been
internalized by the citizens of that
country
( Barr & Serra 2006)
Sifarish – a moral system?
It is a moral system which is accepted and
those participating are often not aware of the
practice
 Morality can be defined as: a system of rules for guiding
human conduct, and principles for evaluating those rules.
 Individual acts within a cultural and social system
If Sifarish is not recognized as part of the
moral fabric of the cultural system and
understood as such
-then, how can we develop tools which
will maximize accountability and
transparency?
What can we do?
1. Recognize that it is a social norm, a pattern
in society and not simply an individual act
2. Include transparent discussion of the
different kinds of acts and their results
3. Discuss the concept of harm to society and
encourage research on not only corruption
but also related topics such as Sifarish
Shukriya....Thank you
Selected References
 Barr A. & Serra D. 2006 Culture and Corruption. Global Poverty Research





Group http:// www.gprg.org, accessed on 21 June, 2010
Nichtar, S. 2007 Corruption: the need-greed equation. News International,
Islamabad, December 09.
Savedoff WD. 2006. The causes of corruption in the health sector: a focus
on health care systems. In: Transparency International. Global Corruption
Report 2006: Special focus on corruption and health. London: Pluto Press.
Taryn Vian, 2008, Review of corruption in the health sector: theory,
methods and interventions. Health Policy and Planning, Vol. 23, pp 83-94.
Taryn Vian, 2002, Corruption and Health care Sector. Transparency
international: Sectoral prospective of corruption, pp 1-35
Transparency International :http://www.transparency.org/ accessed on 19th
February 2010