Abstract
BackgroundThe government of Pakistan introduced devolution in 2001. Responsibility for delivery of most health services passed from provincial to district governments. Two national surveys examined public opinions, use, and experience of health services in 2001 and 2004, to assess the impact of devolution on these services from the point of view of the public.MethodsA stratified random cluster sample drawn in 2001 and revisited in 2004 included households in all districts. Field teams administered a questionnaire covering views about available health services, use of government and private health services, and experience and satisfaction with the service. Focus groups in each community discussed reasons behind the findings, and district nazims (elected mayors) and administrators commented about implementation of devolution. Multivariate analysis, with an adjustment for clustering, examined changes over time, and associations with use and satisfaction with services in 2004.ResultsFew of 57,321 households interviewed in 2002 were satisfied with available government health services (23%), with a similar satisfaction (27%) among 53,960 households in 2004. Less households used government health services in 2004 (24%) than in 2002 (29%); the decrease was significant in the most populous province. In 2004, households were more likely to use government services if they were satisfied with the services, poorer, or less educated. The majority of users of government health services were satisfied; the increase from 63% to 67% between 2002 and 2004 was significant in two provinces. Satisfaction in 2004 was higher among users of private services (87%) or private unqualified practitioners (78%). Users of government services who received all medicines from the facility or who were given an explanation of their condition were more likely to be satisfied. Focus groups explained that people avoid government health services particularly because of bad treatment from staff, and unavailable or poor quality medicines. District nazims and administrators cited problems with implementation of devolution, especially with transfer of funds.ConclusionsUnder devolution, the public did not experience improved government health services, but devolution was not fully implemented as intended. An ongoing social audit process could provide a basis for local and national accountability of health services.
Highlights
The government of Pakistan introduced devolution in 2001
In order to assess the impact of the new local government system from the standpoint of ordinary Pakistani citizens, the National Reconstruction Bureau commissioned an independent social audit process to seek the views and experience of the public about local democracy and several key government services
We examined associations between outcomes of interest and potentially associated variables, first in bivariate analysis and in multivariate analysis using the Mantel Haenszel procedure [7], with an adjustment for clustering described by Gilles Lamothe, based on a variance estimator to weight the Mantel Haenszel odds ratio for cluster-correlated data [8,9]
Summary
The Human Research Review Committee of HOPE (Health Oriented Preventive Education), based in Karachi, Pakistan, reviewed and gave ethical approval for the surveys. Trained members of the teams returned to the districts and sample communities a few months later to conduct the interviews with the district nazims and DCOs (for the later survey only) and the focus group discussions. In each site they attempted to conduct two focus groups, male and female, with 8-10 participants in each group. Initial models for satisfaction of government service users included: vulnerability of the user’s household; urban or rural location; payments made for medicines and to health workers; explanation of the condition; and availability of required medicines. They identified themes about why people avoided using government health services and about what could be done to encourage people to use these services, and extracted relevant quotes
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