Pakistani Healthcare in a poor form Sifarish Pakistani Healthcare in a poor form

Scope Case Study of North West Frontier Province, Pakistan (Khyber Pakhtunkhwa) Health Services Quality Contextual factors that influence mechanisms for quality improvement

Nurses situation in district hospitals Dust at base of tap No soap No hand towels No guideline for washing hands No water Not separated indicting poor hygiene

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 discrepancies Increasing reliance on paramedical 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

Corruption Routes 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

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 There is consistency in the practice of Sifarish (patronage, nepotism, favouritism) It was identified 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) Barr A. & Serra D. 2006 Culture and Corruption. Global Poverty Research Group http:// www.gprg.org, accessed on 21 June, 2010

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

Sifarish implications 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? Recognize that it is a social norm, a pattern in society and not simply an individual act Include transparent discussion of the different kinds of acts and their results Discuss the concept of harm to society and encourage research on not only corruption but also related topics such as Sifarish